BSN Fundamentals of Nursing 2

Question 1

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

Accepted Answer

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

Answer

Placing sterile items at the edge of the sterile drape border

Answer

Opening sterile packages away from the body and dropping items onto the field

Answer

Wearing sterile gloves before touching items on the sterile field

Question 2

When performing a head-to-toe assessment, the nurse auscultates bowel sounds and hears high-pitched, gurgling sounds every 5–15 seconds. How should the nurse document this finding?

Accepted Answer

Normal bowel sounds

Answer

Hypoactive bowel sounds

Answer

Absent bowel sounds

Answer

Hyperactive bowel sounds

Question 3

A patient's urinary output over 8 hours is 200 mL. The nurse recognizes this as:

Accepted Answer

Oliguria

Answer

Polyuria

Answer

Normal urine output

Answer

Anuria

Question 4

Which position is most appropriate for a patient experiencing dyspnea?

Accepted Answer

High Fowler's (90°)

Answer

Supine

Answer

Trendelenburg

Answer

Prone

Question 5

The nurse is about to administer a medication and the patient states, 'That pill looks different than usual.' What is the nurse's priority action?

Accepted Answer

Hold the medication and verify the order

Answer

Reassure the patient and administer the medication

Answer

Document the patient's concern and proceed

Answer

Ask the charge nurse to administer it instead

Question 6

A nurse is teaching a patient about diaphragmatic breathing. Which instruction is correct?

Accepted Answer

Place one hand on the chest and one on the abdomen; the abdomen should rise more

Answer

Breathe rapidly and shallowly to maximize oxygen intake

Answer

Inhale through the mouth and exhale through the nose

Answer

Hold each breath for at least 10 seconds before exhaling

Question 7

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

Accepted Answer

Aspiration of gastric contents with a pH of 1–4

Answer

Aspiration of clear fluid with a pH of 7.4

Answer

Air bubbling when the tube is placed in water

Answer

The patient is able to speak clearly