BSN BS-Nursing General 2 — Questions and Answers
Question 1: A nurse is caring for a patient with heart failure who has dependent edema and crackles bilaterally. Which position is most therapeutic?
- Trendelenburg
- High Fowler's (90°) (Correct answer)
- Prone
- Left lateral Sims'
Correct answer: High Fowler's (90°)
High Fowler's position reduces preload by pooling blood in dependent extremities and eases breathing in heart failure patients.
Question 2: Which electrolyte imbalance is most likely to precipitate digoxin toxicity?
- Hypernatremia
- Hyperkalemia
- Hypokalemia (Correct answer)
- Hypermagnesemia
Correct answer: Hypokalemia
Hypokalemia enhances digoxin binding to cardiac Na+/K+-ATPase receptors, increasing toxicity risk.
Question 3: A patient's ABG results are: pH 7.28, PaCO2 52 mmHg, HCO3 24 mEq/L. What is the correct interpretation?
- Metabolic acidosis
- Respiratory alkalosis
- Respiratory acidosis (Correct answer)
- Metabolic alkalosis
Correct answer: Respiratory acidosis
Elevated PaCO2 with low pH and normal HCO3 indicates uncompensated respiratory acidosis.
Question 4: Under the HIPAA Privacy Rule, which action is permissible without patient authorization?
- Sharing records with an employer for job screening
- Disclosing PHI to law enforcement for a court order (Correct answer)
- Selling patient data to a pharmaceutical company
- Providing records to a friend of the patient
Correct answer: Disclosing PHI to law enforcement for a court order
HIPAA permits disclosure of PHI to law enforcement when required by a court order or subpoena.
Question 5: A nurse administers the wrong medication dose. After notifying the physician, what is the nurse's next priority action?
- File a variance/incident report (Correct answer)
- Inform the charge nurse
- Document the error in the chart as a medication error
- Call the pharmacist to verify the dose
Correct answer: File a variance/incident report
Filing an incident report per institutional policy is required to promote patient safety and system improvement after a medication error.
Question 6: Which finding in a postoperative patient requires the most immediate nursing intervention?
- Urinary output of 45 mL/hour
- Oral temperature of 37.8°C on day 2
- Respiratory rate of 8 breaths/min with SpO2 90% (Correct answer)
- Pain rating of 5/10 at the incision site
Correct answer: Respiratory rate of 8 breaths/min with SpO2 90%
A respiratory rate of 8 with SpO2 of 90% indicates respiratory depression requiring immediate intervention to prevent hypoxic injury.
Question 7: A patient with a serum potassium of 2.9 mEq/L is prescribed IV potassium chloride. Which nursing action is essential?
- Administer the infusion via IV push over 2 minutes
- Infuse no faster than 10–20 mEq/hour via an infusion pump (Correct answer)
- Mix the KCl in a 10 mL saline flush and give rapidly
- Administer only through a central line at any rate
Correct answer: Infuse no faster than 10–20 mEq/hour via an infusion pump
IV potassium must never be given as a bolus; rates exceeding 20 mEq/hour risk fatal cardiac dysrhythmias.
BSN BS-Nursing General 2
A nurse is caring for a patient with heart failure who has dependent edema and crackles bilaterally.
Which position is most therapeutic?