BSN Fundamentals of Nursing 3 — Questions and Answers
Question 1: A nurse is caring for a patient with a stage II pressure injury. Which characteristic best describes this wound?
- Full-thickness skin loss exposing subcutaneous tissue
- Intact skin with non-blanchable redness
- Partial-thickness loss with a shallow open ulcer or intact blister (Correct answer)
- Full-thickness tissue loss with visible bone or muscle
Correct answer: Partial-thickness loss with a shallow open ulcer or intact blister
A stage II pressure injury involves partial-thickness skin loss presenting as a shallow open ulcer or an intact or ruptured serum-filled blister.
Question 2: When administering an intradermal injection for tuberculin skin testing, the nurse should insert the needle at which angle?
- 90 degrees
- 45 degrees
- 5–15 degrees (Correct answer)
- 30 degrees
Correct answer: 5–15 degrees
Intradermal injections are given at a 5–15-degree angle, nearly parallel to the skin, to deposit medication within the dermis.
Question 3: A patient is ordered 0.9% sodium chloride IV at 125 mL/hour. The IV tubing has a drop factor of 15 gtt/mL. What is the correct drip rate in gtt/min?
- 15 gtt/min
- 31 gtt/min (Correct answer)
- 42 gtt/min
- 63 gtt/min
Correct answer: 31 gtt/min
Drip rate = (125 mL/hr × 15 gtt/mL) ÷ 60 min = 1875 ÷ 60 ≈ 31 gtt/min.
Question 4: A nurse is performing ROM exercises on a patient. Moving the patient's ankle so the toes point upward toward the shin is called:
- Plantar flexion
- Inversion
- Dorsiflexion (Correct answer)
- Eversion
Correct answer: Dorsiflexion
Dorsiflexion decreases the angle between the dorsum of the foot and the leg, pointing the toes upward.
Question 5: Which of the following best describes the purpose of the nursing process?
- To follow physician orders accurately
- To provide a systematic, individualized framework for delivering patient care (Correct answer)
- To document patient care for billing purposes
- To standardize care so all patients receive identical treatments
Correct answer: To provide a systematic, individualized framework for delivering patient care
The nursing process (ADPIE) is a systematic, problem-solving framework that guides individualized, evidence-based patient care.
Question 6: A nurse is preparing to give a bed bath. What is the correct water temperature for the bath water?
- 37–40°C (98.6–104°F) (Correct answer)
- 43–46°C (109–115°F)
- 32–35°C (89.6–95°F)
- 48–50°C (118–122°F)
Correct answer: 37–40°C (98.6–104°F)
Bath water should be 37–40°C (98.6–104°F) to be comfortably warm without risk of burns.
Question 7: A nurse is using the SBAR communication tool during a handoff. What does the 'R' stand for?
- Responsibility
- Recommendation (Correct answer)
- Response
- Reassessment
Correct answer: Recommendation
In SBAR, R stands for Recommendation — the nurse's suggested action or plan for the patient.
BSN Fundamentals of Nursing 3
A nurse is caring for a patient with a stage II pressure injury.
Which characteristic best describes this wound?