,Nightingale BSN 225 Exam Review | Health Promotion HESI
Fundamentals V1/V2 Q&A
1. A nurse is preparing to perform an arterial blood gas (ABG) analysis on a patient.
How should the nurse use Allen's test prior to the procedure?
A) To measure the patient's blood pressure.
B) To ensure adequate blood flow through the ulnar artery.
C) To check for signs of infection at the site.
D) To assess the patient's respiratory rate.
Correct Answer: To ensure adequate blood flow through the ulnar artery.
Rationale: Allen's test is performed prior to arterial blood gas (ABG) puncture to
assess collateral circulation. By evaluating the patency of the ulnar artery, the nurse
ensures that if the radial artery is compromised during the procedure, sufficient
blood flow to the hand will still be maintained. This helps prevent ischemic
complications.
2. When a nurse responds to a patient with statements like "all right," "go on," or
"uh-huh," which communication technique is being demonstrated?
A) Asking closed-ended questions
B) Back channeling
C) Demonstrating listening skills
D) Asking open-ended questions
Correct Answer: Back channeling
,Rationale: Back channeling involves using brief, encouraging responses (e.g., "go
on," "uh-huh," "all right") to signal active listening and prompt the patient to
continue speaking. It keeps the conversation flowing without interrupting the
patient's narrative.
3. What is one of the primary responsibilities of a nurse when managing a patient's
pain after surgery?
A) To ignore the patient's request if they seem stable.
B) To suggest alternative therapies without consulting a physician.
C) To assess the patient's pain level and administer medication as prescribed.
D) To wait for the physician to arrive before taking any action.
Correct Answer: To assess the patient's pain level and administer medication as
prescribed.
Rationale: Pain management is a fundamental nursing responsibility. The nurse must
regularly assess the patient's pain using a standardized scale and administer
prescribed analgesics to maintain comfort and promote recovery. Delaying or
ignoring pain is not appropriate and can have negative physiological and
psychological effects.
4. How does a diagnostic label contribute to the nursing process?
A) It serves as a legal document for patient care.
B) It provides a summary of the patient's medical history.
C) It is used solely for billing and insurance purposes.
D) It helps in formulating nursing diagnoses and planning care.
Correct Answer: It helps in formulating nursing diagnoses and planning care.
, Rationale: The diagnostic label is a key component of a nursing diagnosis. It
identifies the patient's response to a health condition based on assessment data,
which directs the selection of appropriate nursing interventions and helps in
formulating the overall plan of care. It is not a legal document, a medical summary,
or primarily for billing.
5. Which step in the nursing process would involve promoting a safe environment for
the patient?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Correct Answer: Implementation
Rationale: Implementation is the phase where the nurse carries out the planned
interventions. This includes actions to promote a safe environment, such as fall
prevention, infection control, and ensuring equipment safety. Assessment involves
data collection, diagnosis involves identifying problems, and planning involves
developing the care strategy.
6. If a nurse observes an increase in drainage on a surgical dressing, what should be
the next step in their documentation process?
A) Only note the increase in drainage without further details.
B) Wait for the next shift to report the change.
C) Document the amount, color, and consistency of the drainage and notify the
physician.
D) Document the findings in the patient's chart at the end of the shift.
Fundamentals V1/V2 Q&A
1. A nurse is preparing to perform an arterial blood gas (ABG) analysis on a patient.
How should the nurse use Allen's test prior to the procedure?
A) To measure the patient's blood pressure.
B) To ensure adequate blood flow through the ulnar artery.
C) To check for signs of infection at the site.
D) To assess the patient's respiratory rate.
Correct Answer: To ensure adequate blood flow through the ulnar artery.
Rationale: Allen's test is performed prior to arterial blood gas (ABG) puncture to
assess collateral circulation. By evaluating the patency of the ulnar artery, the nurse
ensures that if the radial artery is compromised during the procedure, sufficient
blood flow to the hand will still be maintained. This helps prevent ischemic
complications.
2. When a nurse responds to a patient with statements like "all right," "go on," or
"uh-huh," which communication technique is being demonstrated?
A) Asking closed-ended questions
B) Back channeling
C) Demonstrating listening skills
D) Asking open-ended questions
Correct Answer: Back channeling
,Rationale: Back channeling involves using brief, encouraging responses (e.g., "go
on," "uh-huh," "all right") to signal active listening and prompt the patient to
continue speaking. It keeps the conversation flowing without interrupting the
patient's narrative.
3. What is one of the primary responsibilities of a nurse when managing a patient's
pain after surgery?
A) To ignore the patient's request if they seem stable.
B) To suggest alternative therapies without consulting a physician.
C) To assess the patient's pain level and administer medication as prescribed.
D) To wait for the physician to arrive before taking any action.
Correct Answer: To assess the patient's pain level and administer medication as
prescribed.
Rationale: Pain management is a fundamental nursing responsibility. The nurse must
regularly assess the patient's pain using a standardized scale and administer
prescribed analgesics to maintain comfort and promote recovery. Delaying or
ignoring pain is not appropriate and can have negative physiological and
psychological effects.
4. How does a diagnostic label contribute to the nursing process?
A) It serves as a legal document for patient care.
B) It provides a summary of the patient's medical history.
C) It is used solely for billing and insurance purposes.
D) It helps in formulating nursing diagnoses and planning care.
Correct Answer: It helps in formulating nursing diagnoses and planning care.
, Rationale: The diagnostic label is a key component of a nursing diagnosis. It
identifies the patient's response to a health condition based on assessment data,
which directs the selection of appropriate nursing interventions and helps in
formulating the overall plan of care. It is not a legal document, a medical summary,
or primarily for billing.
5. Which step in the nursing process would involve promoting a safe environment for
the patient?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Correct Answer: Implementation
Rationale: Implementation is the phase where the nurse carries out the planned
interventions. This includes actions to promote a safe environment, such as fall
prevention, infection control, and ensuring equipment safety. Assessment involves
data collection, diagnosis involves identifying problems, and planning involves
developing the care strategy.
6. If a nurse observes an increase in drainage on a surgical dressing, what should be
the next step in their documentation process?
A) Only note the increase in drainage without further details.
B) Wait for the next shift to report the change.
C) Document the amount, color, and consistency of the drainage and notify the
physician.
D) Document the findings in the patient's chart at the end of the shift.
