BSN Fundamentals of Nursing 4 — Questions and Answers
Question 1: A patient tells the nurse, 'I feel like my heart is racing.' Which therapeutic communication technique does the nurse use by responding, 'Your heart is racing?'
- Clarifying
- Restating (reflecting) (Correct answer)
- Summarizing
- Open-ended questioning
Correct answer: Restating (reflecting)
Restating (or reflecting) repeats the patient's own words back to them to encourage elaboration.
Question 2: A nurse is evaluating pain using the numeric rating scale (NRS). A patient reports a pain level of 8/10. This pain is classified as:
- Mild
- Moderate
- Severe (Correct answer)
- Intolerable
Correct answer: Severe
On the NRS, 1–3 = mild, 4–6 = moderate, 7–10 = severe pain.
Question 3: When collecting a midstream clean-catch urine specimen, which instruction should the nurse give the patient?
- Collect the first portion of urine into the specimen cup
- Begin voiding, then collect the midstream portion in the cup (Correct answer)
- Collect all urine produced over 24 hours
- Use an in-and-out catheter to collect the specimen
Correct answer: Begin voiding, then collect the midstream portion in the cup
The initial urine stream flushes urethral contaminants; the midstream portion provides the cleanest sample for culture.
Question 4: A nurse is performing a capillary blood glucose check. After the lancet puncture, what should the nurse do before collecting the blood sample?
- Milk the finger vigorously toward the puncture site
- Squeeze the fingertip tightly until blood fills the glucometer strip
- Wipe away the first drop of blood with a clean gauze (Correct answer)
- Apply the tourniquet above the wrist to increase blood flow
Correct answer: Wipe away the first drop of blood with a clean gauze
The first drop of blood is wiped away because it may be contaminated with tissue fluid, which can alter glucose results.
Question 5: A patient is prescribed a medication that should be given sublingually. How should the nurse instruct the patient to take it?
- Swallow the tablet immediately with a full glass of water
- Place the tablet under the tongue and let it dissolve completely (Correct answer)
- Chew the tablet thoroughly before swallowing
- Crush the tablet and mix it with food
Correct answer: Place the tablet under the tongue and let it dissolve completely
Sublingual medications are placed under the tongue to dissolve and absorb directly into the bloodstream via the sublingual mucosa.
Question 6: Which principle guides the nurse in prioritizing care using Maslow's hierarchy of needs?
- Psychosocial needs are always addressed before physiological needs
- Physiological needs must be met before higher-level needs can be addressed (Correct answer)
- All needs are equal and should be addressed simultaneously
- Safety needs take priority over all other needs
Correct answer: Physiological needs must be met before higher-level needs can be addressed
Maslow's hierarchy places physiological needs (airway, breathing, circulation) at the base, meaning they must be addressed first.
Question 7: A nurse is caring for a patient who is NPO (nothing by mouth) before surgery. The patient asks for a sip of water. What is the nurse's best response?
- Allow a small sip since water is clear and will not affect anesthesia
- Deny the request and explain that NPO restrictions reduce aspiration risk during anesthesia (Correct answer)
- Contact the surgeon to revise the NPO order
- Offer ice chips as a compromise
Correct answer: Deny the request and explain that NPO restrictions reduce aspiration risk during anesthesia
NPO status is maintained to minimize gastric contents and reduce the risk of aspiration pneumonia during anesthesia.
BSN Fundamentals of Nursing 4
A patient tells the nurse, 'I feel like my heart is racing.' Which therapeutic communication technique does the nurse use by responding, 'Your heart is racing?'