BSN Fundamentals of Nursing 5

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:

Accepted Answer

Infiltration

Answer

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?

Accepted Answer

Insert the catheter without suction, then apply intermittent suction while withdrawing

Answer

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?

Accepted Answer

Deficit of 8; indicates some cardiac contractions are not producing a palpable peripheral pulse

Answer

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?

Accepted Answer

Tape all four sides of the dressing in a picture-frame pattern

Answer

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?

Accepted Answer

Use the same anatomical region consistently and rotate within that region

Answer

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

BSN - Degree Bachelor of Science in Nursing Practice Test