BSN 206 Foundations of Nursing Fundamentals
Hallmark Exam (Latest Update )
Questions & Answers | 100% Correct | Grade A –
Nightingale College
1. The nurse is preparing to administer a medication via the intramuscular route to a 6-
month-old infant. Which site is most appropriate? Answer: Vastus lateralisRationale:
The vastus lateralis (anterolateral thigh) is the preferred IM injection site for infants
under 12 months due to its larger muscle mass, absence of major nerves and vessels, and
reduced risk of sciatic nerve injury compared to the dorsogluteal site.
2. A client with a history of falls is being admitted to the medical-surgical unit. Which
nursing intervention has the highest priority to prevent falls? Answer: Keep the bed in
the lowest position with side rails upRationale: Keeping the bed in the lowest position
with side rails elevated is the most effective environmental intervention to reduce fall risk
during bed mobility and transfers, per Joint Commission and evidence-based fall
prevention guidelines.
3. The nurse is assessing a client who is postoperative day 1 after abdominal surgery. Which
finding requires immediate intervention? Answer: Respiratory rate of 28 breaths per
minute and oxygen saturation 88% on room airRationale: Tachypnea and hypoxia
are early signs of postoperative pulmonary complications (atelectasis, pneumonia, or
pulmonary embolism). Immediate intervention with supplemental oxygen, repositioning,
incentive spirometry, and provider notification is required.
4. When performing wound irrigation, the nurse should use which type of solution?
Answer: Normal salineRationale: Normal saline (0.9% NaCl) is the preferred irrigant
for most wounds because it is isotonic, non-cytotoxic, and does not interfere with wound
healing. Antiseptics (povidone-iodine, hydrogen peroxide) are cytotoxic to fibroblasts
and should be avoided in clean or granulating wounds.
Hallmark Exam (Latest Update )
Questions & Answers | 100% Correct | Grade A –
Nightingale College
1. The nurse is preparing to administer a medication via the intramuscular route to a 6-
month-old infant. Which site is most appropriate? Answer: Vastus lateralisRationale:
The vastus lateralis (anterolateral thigh) is the preferred IM injection site for infants
under 12 months due to its larger muscle mass, absence of major nerves and vessels, and
reduced risk of sciatic nerve injury compared to the dorsogluteal site.
2. A client with a history of falls is being admitted to the medical-surgical unit. Which
nursing intervention has the highest priority to prevent falls? Answer: Keep the bed in
the lowest position with side rails upRationale: Keeping the bed in the lowest position
with side rails elevated is the most effective environmental intervention to reduce fall risk
during bed mobility and transfers, per Joint Commission and evidence-based fall
prevention guidelines.
3. The nurse is assessing a client who is postoperative day 1 after abdominal surgery. Which
finding requires immediate intervention? Answer: Respiratory rate of 28 breaths per
minute and oxygen saturation 88% on room airRationale: Tachypnea and hypoxia
are early signs of postoperative pulmonary complications (atelectasis, pneumonia, or
pulmonary embolism). Immediate intervention with supplemental oxygen, repositioning,
incentive spirometry, and provider notification is required.
4. When performing wound irrigation, the nurse should use which type of solution?
Answer: Normal salineRationale: Normal saline (0.9% NaCl) is the preferred irrigant
for most wounds because it is isotonic, non-cytotoxic, and does not interfere with wound
healing. Antiseptics (povidone-iodine, hydrogen peroxide) are cytotoxic to fibroblasts
and should be avoided in clean or granulating wounds.
