Mixed Deck — All BSN Topics Flashcards

A child is diagnosed with Tetralogy of Fallot and experiences a hypercyanotic ('Tet') spell. Which position should the nurse place the child in?

Answer: Knee-chest position

The knee-chest position increases systemic vascular resistance, reduces right-to-left shunting, and improves pulmonary blood flow, thereby relieving the hypercyanotic spell.

Which finding indicates that a patient's nasogastric tube is correctly placed in the stomach?

Answer: Aspiration of gastric contents with a pH of 1–4

Gastric aspirate with a pH of 1–4 confirms correct placement in the stomach before administering feedings.

Which electrolyte imbalance increases a patient's risk for digoxin toxicity?

Answer: Hypokalemia

Hypokalemia potentiates digoxin toxicity because low potassium levels increase myocardial sensitivity to the drug.

When using a PCA (patient-controlled analgesia) pump, which action by the patient's family member requires immediate nurse intervention?

Answer: Pressing the PCA button while the patient is sleeping

Only the patient should activate the PCA; proxy dosing by a family member bypasses the safety mechanism and can cause respiratory depression.

A patient receiving epidural analgesia during labor develops sudden hypotension. What is the nurse's priority action?

Answer: Increase IV fluid rate and position patient in left lateral position

Epidural-induced sympathetic blockade causes vasodilation and hypotension; IV fluid bolus and lateral positioning restore cardiac preload and maternal BP.

A patient at 38 weeks' gestation presents with sudden, painless, bright red vaginal bleeding. The nurse suspects which condition?

Answer: Placenta previa

Placenta previa classically presents with painless bright red vaginal bleeding in the third trimester as the low-lying placenta separates.

A nurse uses the SBAR communication tool when handing off a deteriorating patient. What does the 'R' stand for?

Answer: Recommendation

In SBAR, 'R' stands for Recommendation — the nurse's suggested action or plan for addressing the patient's condition.

The sedative found naturally in meat and dairy products, particularly warm milk, which can aid in inducing sleep is:

Answer: Tryptophan

Tryptophan is a natural sedative; hypnotic sedatives include flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome). Tryptophan, an amino acid that induces sleep, is found in protein-rich foods like milk and milk products. Warm milk is a soothing way to rest and a fantastic approach to help you consume the recommended number of servings of Milk and Alternatives each day. All protein-rich foods contain trace levels of tryptophan, an amino acid that helps with sleep. It is a precursor of the neurotransmitters serotonin, which induces sleep, and melatonin, a hormone that also functions as a neurotransmitter.

The nurse is teaching a patient about warfarin therapy. Which food should the patient be instructed to consume consistently rather than avoid entirely?

Answer: Foods high in vitamin K such as leafy green vegetables

Patients on warfarin should maintain a consistent vitamin K intake rather than eliminating it, because sudden changes alter INR.

A nurse is caring for four patients. Which patient should the nurse assess FIRST using the ABCs framework?

Answer: A patient with oxygen saturation of 88% on room air

An oxygen saturation of 88% indicates hypoxia and is an immediate airway/breathing emergency that takes priority over the other concerns.

A nurse is preparing to perform a sterile dressing change. Which action would contaminate the sterile field?

Answer: Reaching across the sterile field to retrieve an item on the opposite side

Reaching across a sterile field contaminates it because the nurse's arm passes over the field, which is not considered sterile.

A community health nurse is teaching a group of adults about colorectal cancer screening. According to the American Cancer Society guidelines, at what age should average-risk adults begin colorectal cancer screening?

Answer: 45 years

The American Cancer Society updated its guidelines in 2018 to recommend that average-risk adults begin colorectal cancer screening at age 45.

A nurse is assessing a febrile 3-year-old with a temperature of 39.5°C (103.1°F). Which initial nursing action is most appropriate?

Answer: Administer acetaminophen per protocol

Administering antipyretics such as acetaminophen per protocol is the priority intervention to safely reduce fever and improve the child's comfort.

Over the course of the 12-hour shift, six clients will be attended by a registered nurse. The RN is in charge of all aspects of care, including developing the care plan, making interventions, and monitoring the care during her shift. The RN will hand off this responsibility to the following RN in charge when her shift is through. What kind of approach is demonstrated by this nursing care?

Answer: Case method

Case Management. For the duration of her whole shift, the nurse is solely responsible for attending to the patient's needs.

A nurse receives a telephone order from a physician. Which is the BEST action to ensure accuracy?

Answer: Read back the complete order to the physician and document 'T.O. read back and verified'

Reading back the entire order and documenting verification is the safest practice to prevent miscommunication errors with telephone orders.

A patient with schizophrenia is receiving clozapine (Clozaril). Which potentially life-threatening adverse effect requires regular monitoring with a complete blood count?

Answer: Agranulocytosis

Clozapine can cause agranulocytosis (severe reduction in white blood cells), making regular CBC monitoring mandatory per the Clozapine REMS program.

A patient taking lithium carbonate reports nausea, tremors, and confusion. The nurse suspects lithium toxicity. What is the priority nursing action?

Answer: Hold the next dose and obtain a serum lithium level

Signs of lithium toxicity require immediately holding the dose and checking the serum level to confirm and guide treatment.

A nurse notes that a patient's IV insertion site is pale, cool, swollen, and the infusion has slowed. The nurse recognizes this as:

Answer: Infiltration

Infiltration occurs when IV fluid leaks into surrounding tissue, causing pallor, coolness, swelling, and slowed infusion rate.

An infant is admitted with pyloric stenosis. Which laboratory finding is most expected due to repeated vomiting?

Answer: Metabolic alkalosis with hypokalemia and hypochloremia

Repeated projectile vomiting of gastric contents causes loss of hydrochloric acid and potassium, resulting in metabolic alkalosis with hypokalemia and hypochloremia.

A nurse is providing discharge teaching to a patient who will self-administer insulin at home. Which site rotation strategy should the nurse teach?

Answer: Use the same anatomical region consistently and rotate within that region

Using the same anatomical region and rotating within it prevents lipodystrophy and provides consistent insulin absorption.