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BSN 225 HESI RN/HESI RN BSN 225 SPECIALTY
FUNDAMENTALS OF NURSING VERSION 1 Final
Exam Newest Exam Preparation With Complete
Questions And Correct Answers With Rationales |
Already Graded A+||Brand New Version!!
1. A nurse is preparing to administer a subcutaneous injection of
heparin. Which action is most appropriate to minimize tissue damage?
A) Massage the site after injection
B) Use the Z-track technique
C) Administer the injection in the abdomen
D) Apply heat to the site before injection
Answer: C) Administer the injection in the abdomen
Rationale: The abdomen is the preferred site for subcutaneous heparin
injections because it has a consistent layer of subcutaneous fat, which
promotes uniform absorption and minimizes tissue trauma. Massaging
the site (A) can increase bruising and hematoma formation. The Z-track
technique (B) is used for intramuscular injections to seal the medication
in muscle tissue, not for subcutaneous injections. Applying heat (D)
vasodilates the area, potentially increasing bleeding risk and altering
absorption.
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2. A client with a nasogastric tube attached to continuous suction
complains of nausea. Which action should the nurse take first?
A) Irrigate the tube with normal saline
B) Check the tube for patency and placement
C) Administer an antiemetic as prescribed
D) Increase the suction pressure
Answer: B) Check the tube for patency and placement
Rationale: Nausea in a client with a nasogastric tube may indicate tube
displacement or obstruction, leading to gastric distention. The nurse
must first assess tube placement and patency to ensure the tube is
functioning correctly. Irrigating (A) or administering antiemetics (C) may
be appropriate after confirming tube position. Increasing suction
pressure (D) could cause mucosal damage and is not a first-line
intervention.
3. A nurse is caring for a postoperative client who is at risk for
developing deep vein thrombosis. Which intervention is most effective
in preventing this complication?
A) Applying sequential compression devices
B) Administering aspirin daily
C) Encouraging frequent leg exercises
D) Keeping the client in a supine position
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Answer: A) Applying sequential compression devices
Rationale: Sequential compression devices (SCDs) promote venous
return by mechanically compressing the lower extremities, reducing
venous stasis and the risk of deep vein thrombosis (DVT). While leg
exercises (C) are beneficial, they may not be consistently performed or
effective in all clients, especially those with limited mobility. Aspirin (B)
is not the standard prophylactic agent for DVT; low-molecular-weight
heparin is preferred. Supine positioning (D) does not address venous
stasis.
4. A client reports pain rated 8 on a scale of 0 to 10. Which of the
following should the nurse assess first?
A) The client's vital signs
B) The location and characteristics of the pain
C) The time of the last analgesic dose
D) The client's medical history
Answer: B) The location and characteristics of the pain
Rationale: The first step in pain assessment is to obtain a
comprehensive description of the pain, including location, intensity,
quality, and duration, to guide interventions. Vital signs (A) are
important but do not provide a complete pain picture. Knowing the last
analgesic dose (C) is relevant but secondary to understanding the pain
itself. Medical history (D) may provide context but is not the immediate
priority.
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5. A nurse is teaching a client with diabetes about foot care. Which
statement indicates a need for further teaching?
A) I will wear cotton socks with seamless toes
B) I will soak my feet daily in warm water
C) I will check my feet every day for blisters
D) I will trim my toenails straight across
Answer: B) I will soak my feet daily in warm water
Rationale: Soaking feet daily can lead to skin maceration and increase
the risk of infection. Clients with diabetes should wash feet with mild
soap and lukewarm water, then dry thoroughly, especially between
toes. Wearing cotton socks (A), daily foot inspections (C), and trimming
toenails straight across (D) are correct practices to prevent injury and
infection.
6. A client is receiving IV fluids at 125 mL/hr. The nurse notes that the
infusion pump is set incorrectly at 150 mL/hr. What is the priority
action?
A) Document the discrepancy in the client's chart
B) Adjust the pump to the correct rate
C) Notify the healthcare provider
D) Assess the client for signs of fluid overload
Answer: B) Adjust the pump to the correct rate
BSN 225 HESI RN/HESI RN BSN 225 SPECIALTY
FUNDAMENTALS OF NURSING VERSION 1 Final
Exam Newest Exam Preparation With Complete
Questions And Correct Answers With Rationales |
Already Graded A+||Brand New Version!!
1. A nurse is preparing to administer a subcutaneous injection of
heparin. Which action is most appropriate to minimize tissue damage?
A) Massage the site after injection
B) Use the Z-track technique
C) Administer the injection in the abdomen
D) Apply heat to the site before injection
Answer: C) Administer the injection in the abdomen
Rationale: The abdomen is the preferred site for subcutaneous heparin
injections because it has a consistent layer of subcutaneous fat, which
promotes uniform absorption and minimizes tissue trauma. Massaging
the site (A) can increase bruising and hematoma formation. The Z-track
technique (B) is used for intramuscular injections to seal the medication
in muscle tissue, not for subcutaneous injections. Applying heat (D)
vasodilates the area, potentially increasing bleeding risk and altering
absorption.
,2|Page
2. A client with a nasogastric tube attached to continuous suction
complains of nausea. Which action should the nurse take first?
A) Irrigate the tube with normal saline
B) Check the tube for patency and placement
C) Administer an antiemetic as prescribed
D) Increase the suction pressure
Answer: B) Check the tube for patency and placement
Rationale: Nausea in a client with a nasogastric tube may indicate tube
displacement or obstruction, leading to gastric distention. The nurse
must first assess tube placement and patency to ensure the tube is
functioning correctly. Irrigating (A) or administering antiemetics (C) may
be appropriate after confirming tube position. Increasing suction
pressure (D) could cause mucosal damage and is not a first-line
intervention.
3. A nurse is caring for a postoperative client who is at risk for
developing deep vein thrombosis. Which intervention is most effective
in preventing this complication?
A) Applying sequential compression devices
B) Administering aspirin daily
C) Encouraging frequent leg exercises
D) Keeping the client in a supine position
,3|Page
Answer: A) Applying sequential compression devices
Rationale: Sequential compression devices (SCDs) promote venous
return by mechanically compressing the lower extremities, reducing
venous stasis and the risk of deep vein thrombosis (DVT). While leg
exercises (C) are beneficial, they may not be consistently performed or
effective in all clients, especially those with limited mobility. Aspirin (B)
is not the standard prophylactic agent for DVT; low-molecular-weight
heparin is preferred. Supine positioning (D) does not address venous
stasis.
4. A client reports pain rated 8 on a scale of 0 to 10. Which of the
following should the nurse assess first?
A) The client's vital signs
B) The location and characteristics of the pain
C) The time of the last analgesic dose
D) The client's medical history
Answer: B) The location and characteristics of the pain
Rationale: The first step in pain assessment is to obtain a
comprehensive description of the pain, including location, intensity,
quality, and duration, to guide interventions. Vital signs (A) are
important but do not provide a complete pain picture. Knowing the last
analgesic dose (C) is relevant but secondary to understanding the pain
itself. Medical history (D) may provide context but is not the immediate
priority.
, 4|Page
5. A nurse is teaching a client with diabetes about foot care. Which
statement indicates a need for further teaching?
A) I will wear cotton socks with seamless toes
B) I will soak my feet daily in warm water
C) I will check my feet every day for blisters
D) I will trim my toenails straight across
Answer: B) I will soak my feet daily in warm water
Rationale: Soaking feet daily can lead to skin maceration and increase
the risk of infection. Clients with diabetes should wash feet with mild
soap and lukewarm water, then dry thoroughly, especially between
toes. Wearing cotton socks (A), daily foot inspections (C), and trimming
toenails straight across (D) are correct practices to prevent injury and
infection.
6. A client is receiving IV fluids at 125 mL/hr. The nurse notes that the
infusion pump is set incorrectly at 150 mL/hr. What is the priority
action?
A) Document the discrepancy in the client's chart
B) Adjust the pump to the correct rate
C) Notify the healthcare provider
D) Assess the client for signs of fluid overload
Answer: B) Adjust the pump to the correct rate
