Nursing School Fundamentals of Nursing 2 — Questions and Answers
Question 1: During assessment, a nurse auscultates the lungs and hears a crackling, bubbling sound on inspiration. This is documented as:
- Rhonchi
- Wheezing
- Crackles (rales) (Correct answer)
- Stridor
Correct answer: Crackles (rales)
Crackles (rales) are discontinuous crackling or bubbling sounds heard on inspiration, often associated with fluid in the airways or alveoli.
Question 2: Which of the following is a correct technique when taking an oral temperature with a glass thermometer?
- Place the thermometer under the tongue for 2 minutes
- Place the thermometer between the cheek and gum
- Wait 15 minutes after the patient drinks cold water before measuring (Correct answer)
- Clean the thermometer before and after use with hot water
Correct answer: Wait 15 minutes after the patient drinks cold water before measuring
Eating, drinking, or smoking can alter oral temperature readings, so the nurse should wait 15–30 minutes after these activities for an accurate result.
Question 3: A nurse applies standard precautions. Which patient condition requires droplet precautions in addition to standard precautions?
- Influenza (Correct answer)
- Tuberculosis
- C. difficile infection
- MRSA wound infection
Correct answer: Influenza
Influenza is transmitted via respiratory droplets and therefore requires droplet precautions in addition to standard precautions.
Question 4: A patient's urine output over 8 hours is 200 mL. How should the nurse interpret this finding?
- Normal output for an 8-hour period
- Slightly above average but acceptable
- Oliguria — below the expected minimum output (Correct answer)
- Anuria — no urine is being produced
Correct answer: Oliguria — below the expected minimum output
Normal urine output is approximately 30 mL/hr; 200 mL over 8 hours (25 mL/hr) is below the minimum threshold and indicates oliguria.
Question 5: When performing a sterile dressing change, the nurse accidentally touches the sterile field with an ungloved hand. What should the nurse do?
- Proceed if the contact was brief
- Apply hand sanitizer and continue
- Discard the sterile field and set up a new one (Correct answer)
- Change gloves and continue using the same field
Correct answer: Discard the sterile field and set up a new one
Any contact with a sterile field by an unsterile item renders the entire field contaminated; a new sterile setup must be prepared.
Question 6: Which nursing intervention is the highest priority for a patient experiencing anaphylaxis?
- Administer diphenhydramine (Benadryl) IV
- Apply a cold compress to reduce swelling
- Administer epinephrine and maintain airway (Correct answer)
- Elevate the head of the bed to 90 degrees
Correct answer: Administer epinephrine and maintain airway
Epinephrine is the first-line treatment for anaphylaxis and maintaining airway patency is the priority because airway compromise can be life-threatening.
Question 7: A nurse is caring for a patient with a nasogastric (NG) tube. Before administering tube feeding, what is the first action?
- Flush the tube with 50 mL of water
- Check residual gastric volume
- Elevate the head of bed to at least 30 degrees
- Verify tube placement by checking pH or x-ray confirmation (Correct answer)
Correct answer: Verify tube placement by checking pH or x-ray confirmation
Verifying NG tube placement before each feeding is the priority to prevent aspiration pneumonia from inadvertent pulmonary feeding.
Nursing School Fundamentals of Nursing 2
During assessment, a nurse auscultates the lungs and hears a crackling, bubbling sound on inspiration.
This is documented as: