BSNl HESIl 225l Fundamentalsl ofl Nursingl Examl Guidel (Latestl 2025/l 2026l Update)l Questionsl &l Answers|l Gradel A|l 100%l Correctl (Verifiedl Solutions)-l Nightingale
Q:l Onl admission,l al clientl presentsl al signedl livingl willl thatl includesl al Dol Notl Resuscitatel (DNR)l prescription.l Whenl thel clientl stopsl breathing,l thel nursel performsl cardiopulmonaryl resuscitationl (CPR)l andl successfullyl revivesl thel client.l Whatl legall issuesl couldl bel broughtl againstl thel nurse?A.l Assault.B.l Battery.C.l Malpractice.D.l Falsel imprisonment.
Answer:
B.l Battery.Rationale Civill lawsl protectl individuall rightsl andl includel intentionall torts,l suchl asl assaultl (anl intentionall threatl tol engagel inl harmfull contactl withl another)l orl batteryl (unwantedl touching).Performingl anyl procedurel againstl thel client'sl wishesl canl potentiallyl createl al legall issue,l suchl asl battery,l evenl ifl thel procedurel isl ofl questionablel benefitl tol thel client.
Q:l Duringl shiftl changel report,l thel nursel receivesl reportl thatl al clientl hasl abnormall heartl sounds.l Whichl placementl ofl thel stethoscopel shouldl thel nursel usel tol hearl thel client'sl heartl sounds?A.l Placel thel stethoscopel belll atl randoml pointsl onl thel posteriorl chest.B.l Usel thel stethoscopel belll overl thel valvularl areasl ofl thel anteriorl chest.C.l Movel thel diaphragml ofl thel stethoscopel overl thel leftl anteriorl chest.D.l Positionl thel diaphragml ofl thel stethoscopel atl Erb'sl pointl onl thel chest.Rationale E.l Abnormall heartl soundsl arel bestl heardl withl thel belll ofl thel stethoscope,l whichl picksl upl lower-pitchedl sounds,l thatl isl placedl atl pointsl onl thel anteriorl chest.
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B.l Usel thel stethoscopel belll overl thel valvularl areasl ofl thel anteriorl chest.Rationale Abnormall heartl soundsl arel bestl heardl withl thel belll ofl thel stethoscope,l whichl picksl upl lower-pitchedl sounds,l thatl isl placedl atl pointsl onl thel anteriorl chest.
Q:l Al malel clientl beingl dischargedl withl al prescriptionl forl thel bronchodilatorl theophyllinel tellsl thel nursel thatl hel understandsl hel isl tol takel threel dosesl ofl thel medicationl eachl day.l Since,l atl thel timel ofl discharge,l timed-releasel capsulesl arel notl available,l whichl dosingl schedulel shouldl thel nursel advisel thel clientl tol follow?A.l 9l a.m.,l 1l p.m.,l andl 5l p.m.B.l 8l a.m.,l 4l p.m.,l andl midnight.C.l Beforel breakfast,l beforel lunch,l andl beforel dinner.D.l Withl breakfast,l withl lunch,l andl withl dinner.
Answer:
B.l 8l a.m.,l 4l p.m.,l andl midnight.Rationale Theophyllinel shouldl bel administeredl onl al regular,l around-the-clockl schedulel tol providel thel bestl bronchodilatingl effectl andl tol reducel thel potentiall forl adversel effects.l Foodl mayl alterl absorptionl ofl thel medication,l sol itl shouldl notl bel takenl withl meals.
Q:l Whichl nutritionall assessmentl datal shouldl thel nursel collectl tol bestl reflectl totall musclel massl inl anl adolescent?A.l Heightl inl inchesl orl centimeters.B.l Weightl inl kilogramsl orl pounds.C.l Tricepsl skinl foldl thickness.D.l Upperl arml circumference.
Answer:
D.l Upperl arml circumference.Rationale Upperl arml circumferencel isl anl indirectl measurel ofl musclel mass.Heightl andl weightl dol notl distinguishl betweenl fatl (adipose)l andl muscularity.Tricepsl skinl foldl thicknessl isl al measurel ofl bodyl fat.
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Q:l Thel nursel noticesl thatl thel Hispanicl parentsl ofl al toddlerl whol returnsl froml surgeryl offerl thel childl onlyl thel brothl thatl comesl onl thel clearl liquidl tray.l Otherl liquids,l includingl gelatin,l popsicles,l andl juices,l remainl untouched.l Whatl explanationl isl mostl appropriatel forl thisl behavior?A.l Thel beliefl isl heldl thatl thel "evill eye"l entersl thel childl ifl anythingl coldl isl ingested.B.l Afterl surgeryl thel childl probablyl hasl refusedl alll foodsl exceptl broth.C.l Eatingl brothl strengthensl thel child'sl innatel energyl calledl "chi." D.l "Hot"l remediesl restorel balancel afterl surgery,l whichl isl consideredl al "cold"l condition.
Answer:
D.l "Hot"l remediesl restorel balancel afterl surgery,l whichl isl consideredl al "cold"l condition.Rationale Commonl parentall practicesl andl healthl beliefsl amongl Hispanic,l Chinese,l Filipino,l andl Arabl culturesl classifyl diseases,l areasl ofl thel body,l andl illnessesl asl "hot"l orl "cold"l andl mustl bel balancedl tol maintainl healthl andl preventl illness.l Thel perceptionl thatl surgeryl isl al "cold"l conditionl impliesl thatl onlyl "hot"l remedies,l suchl asl soup,l shouldl bel usedl tol restorel thel healthyl balancel withinl thel body.
Q:l Anl olderl residentl ofl al long-terml carel facilityl isl nol longerl ablel tol performl self- carel andl isl becomingl progressivelyl weaker.l Thel residentl previouslyl requestedl thatl nol resuscitativel effortsl bel performed,l andl thel familyl requestsl hospicel care.l Whatl actionl shouldl thel nursel implementl first?A.l Reaffirml thel client'sl desirel forl nol resuscitativel efforts.B.l Transferl thel clientl tol al hospicel inpatientl facility.C.l Preparel thel familyl forl thel client'sl impendingl death.D.l Notifyl thel healthcarel providerl ofl thel family'sl request.
Answer:
D.l Notifyl thel healthcarel providerl ofl thel family'sl request.Rationale Whenl al familyl requestsl hospicel care,l thel nursel shouldl firstl communicatel withl thel healthcarel provider.l Hospicel carel isl providedl forl clientsl withl al limitedl lifel expectancy,l whichl mustl bel identifiedl byl thel healthcarel provider.l Oncel thel healthcarel providerl supportsl thel transferl tol hospicel care,l thel nursel canl collaboratel withl thel hospicel staffl andl healthcarel providerl tol determinel whatl additionall carel shouldl bel implemented.
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Q:l Al clientl isl inl thel radiologyl departmentl atl 0900l whenl thel prescriptionl levofloxacinl (Levaquin)l 500l mgl IVl everyl 24l hoursl isl scheduledl tol bel administered.l Thel clientl returnsl tol thel unitl atl 1300.l Whatl isl thel bestl interventionl forl thel nursel tol implement?A.l Contactl thel healthcarel providerl andl completel al medicationl variancel form.B.l Administerl thel Levaquinl atl 1300l andl resumel thel 0900l schedulel inl thel morning.C.l Notifyl thel chargel nursel andl completel anl incidentl reportl tol explainl thel missedl dose.D.l Givel thel missedl dosel atl 1300l andl changel thel schedulel tol administerl dailyl atl 1300.Rationale Tol ensurel thatl al therapeuticl levell ofl medicationl isl maintained,l thel nursel shouldl administerl thel missedl dosel asl soonl asl possible,l andl revisel thel administrationl schedulel accordinglyl tol preventl dangerouslyl increasingl thel levell ofl thel medicationl inl thel bloodstream.l Thel nursel shouldl documentl thel reasonl forl thel latel dose,l butl contactingl thel healt
Answer:
D.l Givel thel missedl dosel atl 1300l andl changel thel schedulel tol administerl dailyl atl 1300.Rationale Tol ensurel thatl al therapeuticl levell ofl medicationl isl maintained,l thel nursel shouldl administerl thel missedl dosel asl soonl asl possible,l andl revisel thel administrationl schedulel accordinglyl tol preventl dangerouslyl increasingl thel levell ofl thel medicationl inl thel bloodstream.l Thel nursel shouldl documentl thel reasonl forl thel latel dose,l butl contactingl thel healthcarel providerl orl thel chargel nursel arel notl warranted.
Q:l Al hospitalizedl malel clientl isl receivingl nasogastricl tubel feedingsl vial al small-borel tubel andl al continuousl pumpl infusion.l Hel reportsl thatl hel hadl al badl boutl ofl severel coughingl al fewl minutesl ago,l butl feelsl finel now.l Whatl actionl isl bestl forl thel nursel tol take?A.l Recordl thel coughingl incident.l Nol furtherl actionl isl requiredl atl thisl time.B.l Stopl thel feeding,l explainl tol thel familyl whyl itl isl beingl stopped,l andl notifyl thel healthcarel provider.C.l Afterl clearingl thel tubel withl 30l mll ofl air,l checkl thel pHl ofl fluidl withdrawnl froml thel tube.D.l Injectl 30l mll ofl airl intol thel tubel whilel auscultatingl thel epigastriuml forl gurgling.
Answer:
C.l Afterl clearingl thel tubel withl 30l mll ofl air,l checkl thel pHl ofl fluidl withdrawnl froml thel tube.Rationale Coughing,l vomiting,l andl suctioningl canl precipitatel displacementl ofl thel tipl ofl thel smalll borel feedingl tubel upwardl intol thel esophagus,l placingl thel clientl atl increasedl riskl forl
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