BSN225 Final Exam 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 an adult patient. Which
site is considered the safest and most preferred for large volume injections in adults?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Correct Answer: C
Expert Explanation: The ventrogluteal site is the preferred site for intramuscular
injections because it is away from major blood vessels and nerves. It is also situated in a
large, well-developed muscle that can handle larger volumes of medication. The
dorsogluteal site is no longer recommended due to the risk of sciatic nerve injury.
2. When assessing a patient’s radial pulse, the nurse notes that the rhythm is irregular. What
is the next appropriate action by the nurse?
A. Measure the apical pulse for one full minute.
B. Assess the pulse for a full 60 seconds.
C. Document the finding as normal for the patient’s age.
,D. Notify the healthcare provider immediately.
Correct Answer: A
Expert Explanation: If a peripheral pulse is irregular, the apical pulse should be assessed
for one full minute to obtain the most accurate heart rate. This allows the nurse to identify
the specific nature of the irregularity or a pulse deficit. Measuring for 60 seconds at the
radial site is helpful, but the apical site is the gold standard for assessment in this scenario.
3. A patient who is bedridden is at high risk for developing deep vein thrombosis (DVT).
Which nursing intervention is most effective in preventing this complication?
A. Massaging the lower extremities daily.
B. Applying sequential compression devices (SCDs).
C. Limiting fluid intake to reduce edema.
D. Keeping the patient’s legs in a dependent position.
Correct Answer: B
Expert Explanation: Sequential compression devices (SCDs) promote venous return by
applying intermittent pressure to the legs, which prevents blood stasis. Massaging the legs
is contraindicated because it could dislodge an existing clot and cause a pulmonary
embolism. Adequate hydration and early mobilization are also key components of DVT
prophylaxis.
, 4. A nurse is caring for a patient who has been diagnosed with Clostridioides difficile (C. diff).
Which infection control precaution must the nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions only
Correct Answer: A
Expert Explanation: C. diff is transmitted via the fecal-oral route, necessitating contact
precautions to prevent the spread of spores. This requires the use of gloves and gowns
when entering the patient’s room and dedicated patient care equipment. Hand hygiene
must be performed with soap and water because alcohol-based rubs are ineffective against
C. diff spores.
5. A patient is scheduled for a major surgery and expresses anxiety about the procedure.
Which statement by the nurse demonstrates the use of therapeutic communication?
A. ‘Don’t worry, your surgeon is the best in the hospital.’
B. ‘Tell me more about what is making you feel anxious.’
C. ‘Everything will be fine once the surgery is over.’
D. ‘Why are you feeling anxious about a routine procedure?’
Correct Answer: B
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to administer an intramuscular injection to an adult patient. Which
site is considered the safest and most preferred for large volume injections in adults?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Correct Answer: C
Expert Explanation: The ventrogluteal site is the preferred site for intramuscular
injections because it is away from major blood vessels and nerves. It is also situated in a
large, well-developed muscle that can handle larger volumes of medication. The
dorsogluteal site is no longer recommended due to the risk of sciatic nerve injury.
2. When assessing a patient’s radial pulse, the nurse notes that the rhythm is irregular. What
is the next appropriate action by the nurse?
A. Measure the apical pulse for one full minute.
B. Assess the pulse for a full 60 seconds.
C. Document the finding as normal for the patient’s age.
,D. Notify the healthcare provider immediately.
Correct Answer: A
Expert Explanation: If a peripheral pulse is irregular, the apical pulse should be assessed
for one full minute to obtain the most accurate heart rate. This allows the nurse to identify
the specific nature of the irregularity or a pulse deficit. Measuring for 60 seconds at the
radial site is helpful, but the apical site is the gold standard for assessment in this scenario.
3. A patient who is bedridden is at high risk for developing deep vein thrombosis (DVT).
Which nursing intervention is most effective in preventing this complication?
A. Massaging the lower extremities daily.
B. Applying sequential compression devices (SCDs).
C. Limiting fluid intake to reduce edema.
D. Keeping the patient’s legs in a dependent position.
Correct Answer: B
Expert Explanation: Sequential compression devices (SCDs) promote venous return by
applying intermittent pressure to the legs, which prevents blood stasis. Massaging the legs
is contraindicated because it could dislodge an existing clot and cause a pulmonary
embolism. Adequate hydration and early mobilization are also key components of DVT
prophylaxis.
, 4. A nurse is caring for a patient who has been diagnosed with Clostridioides difficile (C. diff).
Which infection control precaution must the nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions only
Correct Answer: A
Expert Explanation: C. diff is transmitted via the fecal-oral route, necessitating contact
precautions to prevent the spread of spores. This requires the use of gloves and gowns
when entering the patient’s room and dedicated patient care equipment. Hand hygiene
must be performed with soap and water because alcohol-based rubs are ineffective against
C. diff spores.
5. A patient is scheduled for a major surgery and expresses anxiety about the procedure.
Which statement by the nurse demonstrates the use of therapeutic communication?
A. ‘Don’t worry, your surgeon is the best in the hospital.’
B. ‘Tell me more about what is making you feel anxious.’
C. ‘Everything will be fine once the surgery is over.’
D. ‘Why are you feeling anxious about a routine procedure?’
Correct Answer: B
