SNLE Fundamentals of Nursing 4 — Questions and Answers
Question 1: What is the correct angle for intramuscular injection in the vastus lateralis muscle?
- 90 degrees (Correct answer)
- 45 degrees
- 15 degrees
- 60 degrees
Correct answer: 90 degrees
Intramuscular injections are administered at a 90-degree angle to ensure the medication reaches muscle tissue rather than subcutaneous fat. The vastus lateralis is a common IM site for adults and infants.
Question 2: A patient has a nasogastric tube. Before administering medication, what must the nurse confirm?
- Tube placement in the stomach (Correct answer)
- That the patient is sitting upright only
- Tube color and length
- Patient food preferences
Correct answer: Tube placement in the stomach
Confirming NG tube placement before each use prevents aspiration pneumonia from accidental pulmonary medication instillation. Methods include pH testing of aspirate, X-ray confirmation, or auscultation.
Question 3: Which sign/symptom indicates a fluid volume deficit (dehydration)?
- Decreased skin turgor and dry mucous membranes (Correct answer)
- Bounding pulse and hypertension
- Periorbital edema
- Distended neck veins
Correct answer: Decreased skin turgor and dry mucous membranes
Decreased skin turgor and dry mucous membranes are classic signs of dehydration due to reduced extracellular fluid. Bounding pulse, hypertension, periorbital edema, and distended neck veins indicate fluid excess.
Question 4: What is the purpose of using a draw sheet when repositioning a patient?
- To reduce friction and shear on the skin during repositioning (Correct answer)
- To keep the patient warm
- To secure IV lines
- To measure urine output
Correct answer: To reduce friction and shear on the skin during repositioning
A draw sheet reduces friction and shear forces on vulnerable skin during repositioning, protecting against pressure injury formation. Friction and shear are major contributing factors to skin breakdown in immobile patients.
Question 5: What is the recommended frequency for repositioning bedridden patients to prevent pressure ulcers?
- Every 2 hours (Correct answer)
- Every 30 minutes
- Every 4 hours
- Every 6 hours
Correct answer: Every 2 hours
Evidence-based guidelines recommend repositioning immobile patients every 2 hours to relieve sustained pressure on bony prominences, restore tissue perfusion, and prevent pressure ulcer formation.
Question 6: Which laboratory value indicates the patient may be at risk for bleeding?
- Platelet count of 45,000/mm³ (Correct answer)
- Hemoglobin of 12 g/dL
- White blood cell count of 8,000/mm³
- Sodium of 138 mEq/L
Correct answer: Platelet count of 45,000/mm³
A platelet count of 45,000/mm³ is significantly below the normal range (150,000–400,000/mm³), indicating thrombocytopenia. Low platelets impair clot formation, increasing bleeding risk. The other values are within normal limits.
SNLE Fundamentals of Nursing 4
What is the correct angle for intramuscular injection in the vastus lateralis muscle?