BSN225 Exam 3 Actual Exam Style V3 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to administer an intramuscular injection to a 6-month-old infant.
Which site should the nurse select as the most appropriate for this patient?
A. Vastus lateralis
B. Deltoid muscle
C. Dorsogluteal muscle
D. Ventrogluteal muscle
Correct Answer: A
Expert Explanation: The vastus lateralis is the preferred site for infants because it is the
most developed muscle in this age group. Using the dorsogluteal site is contraindicated due
to the risk of sciatic nerve injury in non-walking children. This muscle group provides a
large surface area for absorption with minimal risk of hitting major blood vessels.
2. When assessing a patient with a Stage 3 pressure injury, which clinical finding should the
nurse expect to observe?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss involving the dermis
C. Full-thickness tissue loss with exposed bone or muscle
,D. Full-thickness skin loss with visible subcutaneous fat
Correct Answer: D
Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss where
subcutaneous fat may be visible, but bone and muscle are not yet exposed. This stage
indicates significant damage to the integumentary layers and requires specialized wound
care. It is differentiated from Stage 4 by the absence of visible deep structures like tendons
or bones.
3. A nurse is caring for a patient on contact precautions for MRSA. Which action by the nurse
demonstrates proper use of personal protective equipment (PPE)?
A. Donning a gown and gloves before entering the patient’s room
B. Wearing a mask when entering within 3 feet of the patient
C. Removing the gown after leaving the patient’s room
D. Using an N95 respirator for all care activities
Correct Answer: A
Expert Explanation: Contact precautions require the nurse to wear a gown and gloves for
all interactions with the patient or their environment. These items must be donned before
entering the room to prevent the spread of resistant organisms. Removal of PPE must occur
before exiting the room to ensure the hallway remains uncontaminated.
,4. The nurse is evaluating a patient’s risk for falls using the Morse Fall Scale. Which factor
would contribute to the highest risk score for this patient?
A. The patient has a history of a fall within the last 3 months
B. The patient is over the age of 65
C. The patient is receiving intravenous fluids
D. The patient wears corrective lenses for vision
Correct Answer: A
Expert Explanation: A history of falling is the strongest predictor of future falls and
carries significant weight on the Morse Fall Scale. Patients who have fallen recently are
often more likely to experience balance or safety issues again. Identifying this history
allows the nurse to implement specific interventions such as bed alarms or frequent
rounding.
5. A nurse is providing discharge teaching to a patient regarding a new prescription for
warfarin. Which statement by the patient indicates a need for further instruction?
A. “I will use a soft-bristled toothbrush to clean my teeth.”
B. “I will report any unusual bruising to my healthcare provider.”
C. “I will increase my intake of spinach and kale to improve my health.”
D. “I will avoid taking aspirin unless my doctor tells me otherwise.”
Correct Answer: C
, Expert Explanation: Warfarin works by interfering with Vitamin K, so a sudden increase
in Vitamin K-rich foods like spinach can decrease the drug’s effectiveness. Patients are
instructed to maintain a consistent intake of these foods rather than increasing them. This
consistency helps maintain the therapeutic range of the International Normalized Ratio
(INR).
6. The nurse is preparing to insert an indwelling urinary catheter. Which action is the priority
to maintain surgical asepsis during the procedure?
A. Cleansing the labia majora before the labia minora
B. Donning clean gloves to open the sterile kit
C. Keeping the sterile field within the nurse’s line of vision
D. Inflating the balloon with sterile water to test it first
Correct Answer: C
Expert Explanation: Maintaining a sterile field requires constant vigilance and keeping the
field within sight at all times to prevent accidental contamination. If a sterile object moves
out of the field of vision or below the waist, it is considered contaminated. This practice is a
fundamental principle of surgical asepsis to prevent healthcare-associated infections.
7. A nurse is assessing a patient’s pain level. The patient states their pain is a ‘7’ on a 0-10
scale, but they are laughing while talking on the phone. What should the nurse do first?
A. Wait until the patient hangs up the phone to reassess
B. Document that the patient is overstating their pain level
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to administer an intramuscular injection to a 6-month-old infant.
Which site should the nurse select as the most appropriate for this patient?
A. Vastus lateralis
B. Deltoid muscle
C. Dorsogluteal muscle
D. Ventrogluteal muscle
Correct Answer: A
Expert Explanation: The vastus lateralis is the preferred site for infants because it is the
most developed muscle in this age group. Using the dorsogluteal site is contraindicated due
to the risk of sciatic nerve injury in non-walking children. This muscle group provides a
large surface area for absorption with minimal risk of hitting major blood vessels.
2. When assessing a patient with a Stage 3 pressure injury, which clinical finding should the
nurse expect to observe?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss involving the dermis
C. Full-thickness tissue loss with exposed bone or muscle
,D. Full-thickness skin loss with visible subcutaneous fat
Correct Answer: D
Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss where
subcutaneous fat may be visible, but bone and muscle are not yet exposed. This stage
indicates significant damage to the integumentary layers and requires specialized wound
care. It is differentiated from Stage 4 by the absence of visible deep structures like tendons
or bones.
3. A nurse is caring for a patient on contact precautions for MRSA. Which action by the nurse
demonstrates proper use of personal protective equipment (PPE)?
A. Donning a gown and gloves before entering the patient’s room
B. Wearing a mask when entering within 3 feet of the patient
C. Removing the gown after leaving the patient’s room
D. Using an N95 respirator for all care activities
Correct Answer: A
Expert Explanation: Contact precautions require the nurse to wear a gown and gloves for
all interactions with the patient or their environment. These items must be donned before
entering the room to prevent the spread of resistant organisms. Removal of PPE must occur
before exiting the room to ensure the hallway remains uncontaminated.
,4. The nurse is evaluating a patient’s risk for falls using the Morse Fall Scale. Which factor
would contribute to the highest risk score for this patient?
A. The patient has a history of a fall within the last 3 months
B. The patient is over the age of 65
C. The patient is receiving intravenous fluids
D. The patient wears corrective lenses for vision
Correct Answer: A
Expert Explanation: A history of falling is the strongest predictor of future falls and
carries significant weight on the Morse Fall Scale. Patients who have fallen recently are
often more likely to experience balance or safety issues again. Identifying this history
allows the nurse to implement specific interventions such as bed alarms or frequent
rounding.
5. A nurse is providing discharge teaching to a patient regarding a new prescription for
warfarin. Which statement by the patient indicates a need for further instruction?
A. “I will use a soft-bristled toothbrush to clean my teeth.”
B. “I will report any unusual bruising to my healthcare provider.”
C. “I will increase my intake of spinach and kale to improve my health.”
D. “I will avoid taking aspirin unless my doctor tells me otherwise.”
Correct Answer: C
, Expert Explanation: Warfarin works by interfering with Vitamin K, so a sudden increase
in Vitamin K-rich foods like spinach can decrease the drug’s effectiveness. Patients are
instructed to maintain a consistent intake of these foods rather than increasing them. This
consistency helps maintain the therapeutic range of the International Normalized Ratio
(INR).
6. The nurse is preparing to insert an indwelling urinary catheter. Which action is the priority
to maintain surgical asepsis during the procedure?
A. Cleansing the labia majora before the labia minora
B. Donning clean gloves to open the sterile kit
C. Keeping the sterile field within the nurse’s line of vision
D. Inflating the balloon with sterile water to test it first
Correct Answer: C
Expert Explanation: Maintaining a sterile field requires constant vigilance and keeping the
field within sight at all times to prevent accidental contamination. If a sterile object moves
out of the field of vision or below the waist, it is considered contaminated. This practice is a
fundamental principle of surgical asepsis to prevent healthcare-associated infections.
7. A nurse is assessing a patient’s pain level. The patient states their pain is a ‘7’ on a 0-10
scale, but they are laughing while talking on the phone. What should the nurse do first?
A. Wait until the patient hangs up the phone to reassess
B. Document that the patient is overstating their pain level
