BSN225 Final Exam Actual Exam Style V2 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is conducting an admission assessment. Which step of the nursing process is the
nurse primarily performing?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Correct Answer: B
Expert Explanation: Assessment is the first step of the nursing process and involves
systematic data collection. It provides the foundation for identifying patient needs and
formulating a plan of care. Without a thorough assessment, subsequent steps like diagnosis
and implementation cannot be accurately performed.
2. A nurse discovers a fire in a patient’s trash can. According to the RACE acronym, what is the
nurse’s first action?
A. Activate the fire alarm
B. Extinguish the fire
C. Rescue the patient from the room
,D. Close all doors and windows
Correct Answer: C
Expert Explanation: The R in RACE stands for Rescue, which is the immediate priority to
ensure patient safety. After removing those in danger, the nurse should then activate the
alarm and confine the fire. This sequence is designed to minimize injury and facilitate a
coordinated emergency response.
3. When performing hand hygiene with soap and water, how long should the nurse scrub
their hands?
A. At least 5 seconds
B. At least 20 seconds
C. At least 60 seconds
D. At least 5 minutes
Correct Answer: B
Expert Explanation: The CDC recommends scrubbing hands for at least 20 seconds to
effectively remove pathogens. Proper friction is necessary to dislodge microorganisms
from the skin surfaces. This duration ensures that all areas, including under nails and
between fingers, are adequately cleaned.
4. A patient is at high risk for skin breakdown. Which Braden Scale score would indicate the
highest risk?
A. 9
, B. 18
C. 14
D. 23
Correct Answer: A
Expert Explanation: The Braden Scale ranges from 6 to 23, with lower scores indicating a
higher risk for pressure ulcers. A score of 9 represents a very high risk, necessitating
immediate preventative interventions. Nurses use this tool to systematically assess sensory
perception, moisture, activity, mobility, nutrition, and friction.
5. Which documentation entry is the most objective?
A. Patient seems very angry today.
B. Patient is uncooperative with the morning routine.
C. Patient’s skin is warm and dry to the touch.
D. Patient appears to be in a lot of pain.
E.
Correct Answer: C
Expert Explanation: Objective data consists of observable and measurable facts gathered
through physical examination or diagnostic tests. Statements about a patient’s mood or
pain are often subjective or interpretive unless supported by specific behavioral
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is conducting an admission assessment. Which step of the nursing process is the
nurse primarily performing?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Correct Answer: B
Expert Explanation: Assessment is the first step of the nursing process and involves
systematic data collection. It provides the foundation for identifying patient needs and
formulating a plan of care. Without a thorough assessment, subsequent steps like diagnosis
and implementation cannot be accurately performed.
2. A nurse discovers a fire in a patient’s trash can. According to the RACE acronym, what is the
nurse’s first action?
A. Activate the fire alarm
B. Extinguish the fire
C. Rescue the patient from the room
,D. Close all doors and windows
Correct Answer: C
Expert Explanation: The R in RACE stands for Rescue, which is the immediate priority to
ensure patient safety. After removing those in danger, the nurse should then activate the
alarm and confine the fire. This sequence is designed to minimize injury and facilitate a
coordinated emergency response.
3. When performing hand hygiene with soap and water, how long should the nurse scrub
their hands?
A. At least 5 seconds
B. At least 20 seconds
C. At least 60 seconds
D. At least 5 minutes
Correct Answer: B
Expert Explanation: The CDC recommends scrubbing hands for at least 20 seconds to
effectively remove pathogens. Proper friction is necessary to dislodge microorganisms
from the skin surfaces. This duration ensures that all areas, including under nails and
between fingers, are adequately cleaned.
4. A patient is at high risk for skin breakdown. Which Braden Scale score would indicate the
highest risk?
A. 9
, B. 18
C. 14
D. 23
Correct Answer: A
Expert Explanation: The Braden Scale ranges from 6 to 23, with lower scores indicating a
higher risk for pressure ulcers. A score of 9 represents a very high risk, necessitating
immediate preventative interventions. Nurses use this tool to systematically assess sensory
perception, moisture, activity, mobility, nutrition, and friction.
5. Which documentation entry is the most objective?
A. Patient seems very angry today.
B. Patient is uncooperative with the morning routine.
C. Patient’s skin is warm and dry to the touch.
D. Patient appears to be in a lot of pain.
E.
Correct Answer: C
Expert Explanation: Objective data consists of observable and measurable facts gathered
through physical examination or diagnostic tests. Statements about a patient’s mood or
pain are often subjective or interpretive unless supported by specific behavioral
