BSN225 Exam 4 Actual Exam Style V2 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to perform hand hygiene. Which action is the most important step in
the hand-washing process?
A. Rinsing from fingers to wrists
B. Using hot water to kill the microorganisms
C. Washing for at least 5 seconds
D. Using friction to rub all surfaces of the hands together
Correct Answer: D
Expert Explanation: Friction is the most effective way to remove transient bacteria and
soil from the skin. The nurse should rub the hands together vigorously for at least 20
seconds to ensure cleanliness. Effective hand hygiene is the single most important action to
prevent the spread of infection.
2. A fire is discovered in a patient’s room. Using the RACE acronym, which action should the
nurse take first?
A. Rescue and remove the patient
B. Activate the fire alarm
C. Close the door to confine the fire
,D. Extinguish the fire with a portable extinguisher
Correct Answer: A
Expert Explanation: The first priority in the RACE acronym is to rescue and remove
patients in immediate danger. After the patient is safe, the nurse should activate the alarm
and contain the fire by closing doors. This sequence ensures patient safety before focusing
on equipment or the environment.
3. The nurse notes a patient has a partial-thickness loss of dermis presenting as a shallow
open ulcer with a red-pink wound bed. How should this be documented?
A. Stage I pressure injury
B. Stage III pressure injury
C. Stage II pressure injury
D. Unstageable pressure injury
Correct Answer: C
Expert Explanation: A Stage II pressure injury involves partial-thickness loss of skin with
exposed dermis. It presents as a shiny or dry shallow ulcer without slough or bruising.
Proper staging is essential for determining the appropriate wound care interventions and
monitoring healing progress.
4. A nurse is assessing a patient for orthostatic hypotension. Which finding indicates the
patient is experiencing this condition?
A. A drop in systolic blood pressure of 20 mmHg when moving from supine to standing
, B. A pulse rate that decreases when sitting up
C. A diastolic blood pressure that remains the same when standing
D. A rise in systolic blood pressure of 10 mmHg when standing
Correct Answer: A
Expert Explanation: Orthostatic hypotension is defined as a drop in systolic blood
pressure of at least 20 mmHg or diastolic of at least 10 mmHg within three minutes of
standing. It often causes dizziness or lightheadedness and increases the risk of falls in
elderly patients. Nurses must monitor these changes carefully when a patient begins
ambulating after prolonged bed rest.
5. When administering medications, which of the following represents the ‘Six Rights’ of
medication administration?
A. Patient, Medication, Dose, Route, Time, Documentation
B. Patient, Room Number, Dose, Frequency, Reason, Signature
C. Medication, Pharmacy, Route, Dose, Time, Physician
D. Order, Supply, Patient, Time, Dose, Diagnosis
Correct Answer: A
Expert Explanation: The six rights are the standard for ensuring medication safety: right
patient, drug, dose, route, time, and documentation. Verifying these rights helps prevent
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to perform hand hygiene. Which action is the most important step in
the hand-washing process?
A. Rinsing from fingers to wrists
B. Using hot water to kill the microorganisms
C. Washing for at least 5 seconds
D. Using friction to rub all surfaces of the hands together
Correct Answer: D
Expert Explanation: Friction is the most effective way to remove transient bacteria and
soil from the skin. The nurse should rub the hands together vigorously for at least 20
seconds to ensure cleanliness. Effective hand hygiene is the single most important action to
prevent the spread of infection.
2. A fire is discovered in a patient’s room. Using the RACE acronym, which action should the
nurse take first?
A. Rescue and remove the patient
B. Activate the fire alarm
C. Close the door to confine the fire
,D. Extinguish the fire with a portable extinguisher
Correct Answer: A
Expert Explanation: The first priority in the RACE acronym is to rescue and remove
patients in immediate danger. After the patient is safe, the nurse should activate the alarm
and contain the fire by closing doors. This sequence ensures patient safety before focusing
on equipment or the environment.
3. The nurse notes a patient has a partial-thickness loss of dermis presenting as a shallow
open ulcer with a red-pink wound bed. How should this be documented?
A. Stage I pressure injury
B. Stage III pressure injury
C. Stage II pressure injury
D. Unstageable pressure injury
Correct Answer: C
Expert Explanation: A Stage II pressure injury involves partial-thickness loss of skin with
exposed dermis. It presents as a shiny or dry shallow ulcer without slough or bruising.
Proper staging is essential for determining the appropriate wound care interventions and
monitoring healing progress.
4. A nurse is assessing a patient for orthostatic hypotension. Which finding indicates the
patient is experiencing this condition?
A. A drop in systolic blood pressure of 20 mmHg when moving from supine to standing
, B. A pulse rate that decreases when sitting up
C. A diastolic blood pressure that remains the same when standing
D. A rise in systolic blood pressure of 10 mmHg when standing
Correct Answer: A
Expert Explanation: Orthostatic hypotension is defined as a drop in systolic blood
pressure of at least 20 mmHg or diastolic of at least 10 mmHg within three minutes of
standing. It often causes dizziness or lightheadedness and increases the risk of falls in
elderly patients. Nurses must monitor these changes carefully when a patient begins
ambulating after prolonged bed rest.
5. When administering medications, which of the following represents the ‘Six Rights’ of
medication administration?
A. Patient, Medication, Dose, Route, Time, Documentation
B. Patient, Room Number, Dose, Frequency, Reason, Signature
C. Medication, Pharmacy, Route, Dose, Time, Physician
D. Order, Supply, Patient, Time, Dose, Diagnosis
Correct Answer: A
Expert Explanation: The six rights are the standard for ensuring medication safety: right
patient, drug, dose, route, time, and documentation. Verifying these rights helps prevent
