BSN Fundamentals of Nursing 5 — Questions and Answers
Question 1: A nurse notes that a patient's IV insertion site is pale, cool, swollen, and the infusion has slowed. The nurse recognizes this as:
- Phlebitis
- Infection
- Infiltration (Correct answer)
- Air embolism
Correct answer: Infiltration
Infiltration occurs when IV fluid leaks into surrounding tissue, causing pallor, coolness, swelling, and slowed infusion rate.
Question 2: Which is the correct technique when performing tracheostomy suctioning?
- Apply suction continuously while inserting the catheter to clear the airway
- Insert the catheter without suction, then apply intermittent suction while withdrawing (Correct answer)
- Suction for up to 30 seconds per pass to ensure thorough clearance
- Use suction on both insertion and withdrawal to maximize secretion removal
Correct answer: Insert the catheter without suction, then apply intermittent suction while withdrawing
Suction is applied only during catheter withdrawal using intermittent pressure to prevent mucosal trauma and hypoxia.
Question 3: A patient's apical pulse is 88 bpm and the radial pulse is 80 bpm. What is the pulse deficit, and what does it indicate?
- Deficit of 8; indicates some cardiac contractions are not producing a palpable peripheral pulse (Correct answer)
- Deficit of 8; indicates hypertension
- No deficit; both values are within normal limits
- Deficit of 8; indicates bradycardia
Correct answer: Deficit of 8; indicates some cardiac contractions are not producing a palpable peripheral pulse
A pulse deficit (apical minus radial) indicates that some ventricular contractions are too weak to produce a peripheral pulse wave.
Question 4: When applying a dry sterile dressing, the nurse should use which type of tape application to secure the dressing edges?
- Circumferential taping around the entire extremity to ensure firm adhesion
- Tape only the center of the dressing to allow drainage to escape the edges
- Tape all four sides of the dressing in a picture-frame pattern (Correct answer)
- Tape diagonally across the dressing for maximal hold
Correct answer: Tape all four sides of the dressing in a picture-frame pattern
Taping all four sides in a picture-frame pattern secures the dressing and maintains a sterile barrier without restricting circulation.
Question 5: A nurse is providing discharge teaching to a patient who will self-administer insulin at home. Which site rotation strategy should the nurse teach?
- Rotate injections randomly across all body sites each day for even distribution
- Use the same anatomical region consistently and rotate within that region (Correct answer)
- Always inject in the abdomen because it has the fastest absorption
- Alternate between the arm and thigh daily to promote even insulin absorption
Correct 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.
Question 6: Which laboratory value indicates a patient may be at risk for impaired wound healing?
- Serum albumin 2.1 g/dL (Correct answer)
- Hemoglobin 14 g/dL
- WBC 7,500/mm³
- Platelet count 250,000/mm³
Correct answer: Serum albumin 2.1 g/dL
Serum albumin below 3.5 g/dL indicates protein malnutrition, which impairs collagen synthesis and wound healing.
Question 7: A nurse is teaching a patient to use a cane. The cane should be held on which side, and how high should it be adjusted?
- On the weaker side; adjusted so the elbow is straight
- On the stronger side; adjusted to the level of the greater trochanter with a 20–30° elbow flexion (Correct answer)
- On the weaker side; adjusted to waist height
- On either side; height does not affect gait mechanics
Correct answer: On the stronger side; adjusted to the level of the greater trochanter with a 20–30° elbow flexion
The cane is held on the stronger side to bear weight opposite the weak leg, and adjusted to the greater trochanter with slight elbow flexion for optimal support.
BSN Fundamentals of Nursing 5
A nurse notes that a patient's IV insertion site is pale, cool, swollen, and the infusion has slowed.
The nurse recognizes this as: