BSN225 Exam 4 Actual Exam Style V3 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a client who has a prescription for a clear liquid diet. Which food
choice by the client indicates an understanding of the diet?
A. Apple juice
B. Vanilla pudding
C. Orange juice with pulp
D. Cream of mushroom soup
Correct Answer: A
Expert Explanation: Apple juice is a clear liquid because it is transparent to light and
liquid at room temperature. Clear liquid diets are intended to provide fluids and
electrolytes without leaving undigested residue in the gastrointestinal tract. Choices like
pudding, pulp-filled juice, and cream soups are considered part of a full liquid diet.
2. When assessing a client for hypoxia, which of the following is an early clinical
manifestation the nurse should identify?
A. Cyanosis
B. Bradycardia
C. Restlessness
,D. Hypotension
Correct Answer: C
Expert Explanation: Restlessness and agitation are early signs of hypoxia as the brain is
highly sensitive to decreasing oxygen levels. Cyanosis and bradycardia are considered late
signs indicating significant physiological decompensation. The nurse must prioritize early
assessment to prevent further respiratory or cardiac distress.
3. A nurse is preparing to administer a tap water enema to a client. Which position should the
nurse place the client in?
A. Sims’ position
B. Right lateral with knees flexed
C. Supine
D. High-Fowler’s position
Correct Answer: A
Expert Explanation: The Sims’ position, or left lateral position with the right knee flexed,
allows the enema solution to flow by gravity into the sigmoid colon and rectum. This
anatomical positioning facilitates the distribution of the fluid and minimizes discomfort for
the client. Placing a client in supine or Fowler’s would be inappropriate and potentially
dangerous for this procedure.
, 4. A nurse is documenting the assessment of a pressure injury that involves full-thickness skin
loss with visible adipose tissue but no exposed bone or muscle. Which stage should the nurse
document?
A. Stage I
B. Stage II
C. Stage IV
D. Stage III
Correct Answer: D
Expert Explanation: Stage III pressure injuries involve full-thickness skin loss where
subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. Stage II is
characterized by partial-thickness loss of the dermis, while Stage IV involves exposed bone
or muscle. Accurate staging is essential for implementing the correct wound care protocol
and tracking healing progress.
5. The nurse is reviewing the lab results of a client with a suspected fluid volume deficit.
Which finding is consistent with this diagnosis?
A. Decreased hematocrit
B. Low serum sodium
C. Decreased blood urea nitrogen (BUN)
D. Increased urine specific gravity
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a client who has a prescription for a clear liquid diet. Which food
choice by the client indicates an understanding of the diet?
A. Apple juice
B. Vanilla pudding
C. Orange juice with pulp
D. Cream of mushroom soup
Correct Answer: A
Expert Explanation: Apple juice is a clear liquid because it is transparent to light and
liquid at room temperature. Clear liquid diets are intended to provide fluids and
electrolytes without leaving undigested residue in the gastrointestinal tract. Choices like
pudding, pulp-filled juice, and cream soups are considered part of a full liquid diet.
2. When assessing a client for hypoxia, which of the following is an early clinical
manifestation the nurse should identify?
A. Cyanosis
B. Bradycardia
C. Restlessness
,D. Hypotension
Correct Answer: C
Expert Explanation: Restlessness and agitation are early signs of hypoxia as the brain is
highly sensitive to decreasing oxygen levels. Cyanosis and bradycardia are considered late
signs indicating significant physiological decompensation. The nurse must prioritize early
assessment to prevent further respiratory or cardiac distress.
3. A nurse is preparing to administer a tap water enema to a client. Which position should the
nurse place the client in?
A. Sims’ position
B. Right lateral with knees flexed
C. Supine
D. High-Fowler’s position
Correct Answer: A
Expert Explanation: The Sims’ position, or left lateral position with the right knee flexed,
allows the enema solution to flow by gravity into the sigmoid colon and rectum. This
anatomical positioning facilitates the distribution of the fluid and minimizes discomfort for
the client. Placing a client in supine or Fowler’s would be inappropriate and potentially
dangerous for this procedure.
, 4. A nurse is documenting the assessment of a pressure injury that involves full-thickness skin
loss with visible adipose tissue but no exposed bone or muscle. Which stage should the nurse
document?
A. Stage I
B. Stage II
C. Stage IV
D. Stage III
Correct Answer: D
Expert Explanation: Stage III pressure injuries involve full-thickness skin loss where
subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. Stage II is
characterized by partial-thickness loss of the dermis, while Stage IV involves exposed bone
or muscle. Accurate staging is essential for implementing the correct wound care protocol
and tracking healing progress.
5. The nurse is reviewing the lab results of a client with a suspected fluid volume deficit.
Which finding is consistent with this diagnosis?
A. Decreased hematocrit
B. Low serum sodium
C. Decreased blood urea nitrogen (BUN)
D. Increased urine specific gravity
