BSN BS-Nursing General 4 — Questions and Answers
Question 1: A nurse is teaching a patient with type 2 diabetes about the 'Sick Day Rules.' Which instruction is most important?
- Stop taking all oral hypoglycemics when ill
- Increase fluid intake and continue monitoring blood glucose (Correct answer)
- Fast until nausea subsides to prevent hypoglycemia
- Reduce insulin dose by half when unable to eat
Correct answer: Increase fluid intake and continue monitoring blood glucose
Illness raises blood glucose due to stress hormones; patients must stay hydrated, monitor glucose frequently, and not stop medications without guidance.
Question 2: A patient is prescribed metformin and is scheduled for a contrast CT scan. Which nursing action is most appropriate?
- Administer metformin as scheduled on the morning of the scan
- Hold metformin 48 hours before and after the contrast procedure (Correct answer)
- Double the metformin dose after the scan to compensate
- Switch the patient to insulin permanently before the scan
Correct answer: Hold metformin 48 hours before and after the contrast procedure
Contrast media can impair renal function, causing metformin accumulation and lactic acidosis; it must be withheld around the procedure.
Question 3: When implementing the SBAR communication tool, what information is conveyed in the 'Assessment' component?
- The patient's name, age, and admitting diagnosis
- The nurse's clinical judgment about what is happening with the patient (Correct answer)
- Specific actions the nurse wants the provider to take
- Recent changes in vital signs and test results
Correct answer: The nurse's clinical judgment about what is happening with the patient
The 'A' in SBAR is the nurse's clinical interpretation or assessment of the patient's current problem.
Question 4: A nurse is caring for a patient with increased intracranial pressure (ICP). Which position is contraindicated?
- Head of bed elevated 30°
- Head midline and neutral
- Trendelenburg (head-down) position (Correct answer)
- Slight reverse Trendelenburg
Correct answer: Trendelenburg (head-down) position
Trendelenburg increases venous pressure in the cerebral vasculature, further elevating intracranial pressure.
Question 5: Which finding is an early sign of increased intracranial pressure in an adult?
- Bradycardia with widened pulse pressure
- Altered level of consciousness and headache (Correct answer)
- Fixed and dilated pupils
- Cheyne-Stokes respirations
Correct answer: Altered level of consciousness and headache
Altered LOC and headache are early manifestations; Cushing's triad (bradycardia, hypertension, irregular respirations) and fixed pupils are late, ominous signs.
Question 6: A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. What is the recommended flow rate to avoid suppressing the hypoxic drive?
- 6–8 L/min via simple face mask
- 10–12 L/min via non-rebreather mask
- 1–2 L/min via nasal cannula (Correct answer)
- 15 L/min via bag-valve mask
Correct answer: 1–2 L/min via nasal cannula
COPD patients may rely on hypoxic drive; low-flow O2 at 1–2 L/min raises SpO2 to ~88–92% without eliminating the ventilatory stimulus.
Question 7: A nurse is administering heparin subcutaneously. Which technique is correct?
- Aspirate before injecting to confirm no blood vessel was entered
- Inject into the deltoid muscle for faster absorption
- Do not aspirate; inject into abdominal fatty tissue and do not massage afterward (Correct answer)
- Rub the site vigorously after injection to promote absorption
Correct answer: Do not aspirate; inject into abdominal fatty tissue and do not massage afterward
Subcutaneous heparin should not be aspirated or massaged; aspiration can cause trauma, and massage increases bruising and risk of hematoma.
BSN BS-Nursing General 4
A nurse is teaching a patient with type 2 diabetes about the 'Sick Day Rules.' Which instruction is most important?