BSNl HESIl 225l Fundamentalsl ofl Nursingl Examl (2025/l 2026l Update)l Questionsl &l Answers|l Gradel A|l 100%l Correctl (Verifiedl Solutions)-l Nightingale
Q:l Whichl clientl carel activityl requiresl thel nursel tol wearl barrierl glovesl asl requiredl byl thel protocoll forl Standardl Precautions?Removingl thel emptyl foodl trayl froml al clientl withl al urinaryl catheter.Washingl andl combingl thel hairl ofl al clientl withl al fracturedl legl inl traction.Administeringl orall medicationsl tol al cooperativel clientl withl al woundl infection.Emptyingl thel urinaryl catheterl drainagel bagl forl al clientl withl Alzheimer'sl disease.
Answer:
Emptyingl thel urinaryl catheterl drainagel bagl forl al clientl withl Alzheimer'sl disease.
Rationale
Possiblel contactl withl bodyl secretions,l excretions,l orl brokenl skinl isl anl indicationl forl wearingl barrierl (nonsterile)l gloves.l Emptyingl al urinel drainagel bagl requiresl thel usel ofl glovesl (D).l (A,l B,l andl C)l dol notl requirel gloves.
Q:l Whenl thel nursel entersl al client'sl rooml tol dol anl initiall assessment,l thel clientl shouts,l "Getl outl ofl myl room!l I'ml tiredl ofl beingl bothered!"l Howl shouldl thel nursel respond?"Therel isl nol reasonl tol bel sol angry." "Whyl dol Il needl tol leavel yourl room?" "Whatl isl concerningl youl thisl morning?" "Letl mel calll thel clientl advocatel forl you."
Answer:
"Whatl isl concerningl youl thisl morning?"
Rationale
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(C)l isl anl open-endedl questionl thatl encouragesl thel clientl tol discussl personall feelings.l (A)l devaluesl thel clientl andl hindersl furtherl communication.l Actingl defensivelyl andl askingl "why"l questionsl suchl asl (B)l arel likelyl tol elicitl morel angerl andl blockl communication.l Byl deferringl tol thel clientl advocatel (D),l thel nursel failsl tol evenl addressl thel client'sl feelingsl ofl angerl andl exasperation.
Q:l Al malel nursel isl assignedl tol carel forl al femalel Musliml client.l Whenl thel nursel offersl tol bathel thel client,l thel clientl requestsl thatl al femalel nursel performl thisl task.l Howl shouldl thel malel nursel respond?"Mayl Il askl yourl daughterl tol helpl youl withl yourl personall hygiene?" "Il willl askl onel ofl thel femalel nursesl tol bathel you." "Al staffl memberl onl thel nextl shiftl willl helpl you." "Il willl keepl youl drapedl andl handl youl thel suppliesl asl youl needl them."
Answer:
"Il willl askl onel ofl thel femalel nursesl tol bathel you."
Rationale Manyl femalel Musliml clientsl arel veryl modestl andl preferl tol receivel personall carel froml anotherl femalel becausel ofl theirl religiousl andl culturall beliefs.l Thel mostl culturallyl sensitivel responsel isl forl thel malel nursel tol askl al femalel colleaguel tol performl thisl task.
Q:l Al malel clientl hasl al nursingl diagnosisl ofl "spirituall distress."l Whatl interventionl isl bestl forl thel nursel tol implementl whenl caringl forl thisl client?Usel distractionl techniquesl duringl timesl ofl spirituall stressl andl crisis.Reassurel thel clientl thatl hisl faithl willl bel regainedl withl timel andl support.Consultl withl thel staffl chaplainl andl askl thatl thel chaplainl visitl withl thel client.Usel reflectivel listeningl techniquesl whenl thel clientl expressesl spirituall doubts.
Answer:
Usel reflectivel listeningl techniquesl whenl thel clientl expressesl spirituall doubts.
Rationale
Thel mostl beneficiall nursingl interventionl isl tol usel nonjudgmentall reflectivel listeningl techniques,l tol allowl thel clientl tol feell comfortablel expressingl hisl concernsl (D).l (Al andl B)l arel notl therapeutic.l Thel clientl shouldl bel consultedl beforel implementingl (C).
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Q:l Al 73-year-oldl Hispanicl clientl isl seenl atl thel communityl healthl clinicl withl al historyl ofl proteinl malnutrition.l Whatl informationl shouldl thel nursel obtainl first?Amountl ofl liquidl proteinl supplementsl consumedl daily.Foodsl andl liquidsl consumedl duringl thel pastl 24l hours.Usuall weeklyl intakel ofl milkl productsl andl redl meats.Grainsl andl legumel combinationsl usedl byl thel client.
Answer:
Foodsl andl liquidsl consumedl duringl thel pastl 24l hours.
Rationale
Al client'sl dietaryl habitsl shouldl bel determinedl firstl byl thel client'sl dietaryl recalll (B)l beforel suggestingl proteinl sourcesl orl supplementsl (Al andl C)l asl optionsl inl thel client'sl diet.l Althoughl grainsl andl legumesl (D)l containl incompletel proteinsl thatl reducesl thel essentiall aminol acidl poolsl insidel thel cells,l thel client'sl culturall preferencesl shouldl bel elicitedl afterl confirmingl thel client'sl dietaryl history.
Q:l Thel nursel removesl thel dressingl onl al client'sl heell thatl isl coveringl al pressurel sorel one-inchl inl diameterl andl findsl thatl therel isl straw-coloredl drainagel seepingl froml thel wound.l Whatl descriptionl ofl thisl findingl shouldl thel nursel includel inl thel client'sl record?Stagel 1l pressurel sorel drainingl sero-sanguineousl drainage.Pressurel sorel atl bonyl prominencel withl exudatel noted.One-inchl pressurel sorel drainingl serousl fluid.Pressurel sorel onl heell withl al smalll amountl ofl purulentl drainage.
Answer:
One-inchl pressurel sorel drainingl serousl fluid.
Rationale
Serousl drainagel isl clearl wateryl plasma,l sol (C)l providesl accuratel documentationl basedl onl thel informationl provided.l Informationl tol stagel thisl pressurel scorel (A)l isl notl provided,l andl sero-sanguineousl drainagel isl palel andl wateryl withl al combinationl ofl plasmal andl redl cells,l andl mayl bel blood-streaked.l Exudatel (B)l isl fluidl suchl asl pusl andl serum.l Purulentl drainagel (D)l isl thick,l yellow,l green,l orl brownl indicatingl thel presencel ofl deadl orl livingl organismsl andl whitel bloodl cells.
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Q:l Al femalel clientl whol hasl breastl cancerl withl metastasisl tol thel liverl andl spinel isl admittedl withl constant,l severel painl despitel around-the-clockl usel ofl oxycodonel (Percodan)l andl amitriptylinel (Elavil)l forl painl controll atl home.l Duringl thel admissionl assessment,l whichl informationl isl mostl importantl forl thel nursel tol obtain?Sensoryl pattern,l area,l intensity,l andl naturel ofl thel pain.Triggerl pointsl identifiedl byl palpationl andl manuall pressurel ofl painfull areas.Schedulel andl totall dosagesl ofl drugsl currentlyl usedl forl breakthroughl pain.Sympatheticl responsesl consistentl withl onsetl ofl acutel pain.
Answer:
Sensoryl pattern,l area,l intensity,l andl naturel ofl thel pain.
Rationale
Thel componentsl ofl everyl painl assessmentl shouldl includel sensoryl patterns,l area,l intensity,l andl naturel (PAIN)l ofl thel painl (A)l andl arel essentiall inl identifyingl appropriatel therapyl forl thel client'sl specificl typel andl severityl ofl pain,l whichl mayl indicatel thel onsetl ofl diseasel progressionl orl complications.l Triggersl (B),l currentl drugl usagel (C),l andl sympatheticl responsesl (D),l suchl asl tachycardia,l diaphoresis,l andl elevatedl bloodl pressure,l arel important,l butl shouldl bel obtainedl afterl focusingl onl (A).
Q:l Whatl clientl statementl indicatesl tol thel nursel thatl thel clientl requiresl assistancel withl bathing?"Il wasn'tl ablel tol packl al bagl beforel Il leftl forl thel hospital." "Il don'tl understandl whyl I'ml sol weakl andl tired." "Il onlyl bathel everyl otherl day." "Il leftl myl eyeglassesl atl home."
Answer:
"Il don'tl understandl whyl I'ml sol weakl andl tired."
Rationale
Bathingl oftenl makesl al clientl feell weak,l andl ifl al clientl isl alreadyl feelingl weakl (B),l assistancel isl requiredl duringl thel bathingl processl tol ensurel thel client'sl safety.l (Al andl C)l dol notl posel safetyl issues.l Althoughl (D)l mayl posel al safetyl issue,l furtherl assessmentl isl neededl tol determinel ifl thisl inl factl posesl al safetyl issuel forl thel client.
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