BSN Fundamentals of Nursing 2 — Questions and Answers
Question 1: A nurse is preparing to perform a sterile dressing change. Which action would contaminate the sterile field?
- Placing sterile items at the edge of the sterile drape border
- Opening sterile packages away from the body and dropping items onto the field
- Reaching across the sterile field to retrieve an item on the opposite side (Correct answer)
- Wearing sterile gloves before touching items on the sterile field
Correct answer: Reaching across the sterile field to retrieve an item on the opposite side
Reaching across a sterile field contaminates it because the nurse's arm passes over the field, which is not considered sterile.
Question 2: When performing a head-to-toe assessment, the nurse auscultates bowel sounds and hears high-pitched, gurgling sounds every 5–15 seconds. How should the nurse document this finding?
- Hypoactive bowel sounds
- Absent bowel sounds
- Hyperactive bowel sounds
- Normal bowel sounds (Correct answer)
Correct answer: Normal bowel sounds
Normal bowel sounds occur every 5–30 seconds and are described as high-pitched, gurgling sounds.
Question 3: A patient's urinary output over 8 hours is 200 mL. The nurse recognizes this as:
- Polyuria
- Normal urine output
- Oliguria (Correct answer)
- Anuria
Correct answer: Oliguria
Oliguria is defined as urine output less than 30 mL/hour; 200 mL over 8 hours equals 25 mL/hour, which is oliguria.
Question 4: Which position is most appropriate for a patient experiencing dyspnea?
- Supine
- Trendelenburg
- High Fowler's (90°) (Correct answer)
- Prone
Correct answer: High Fowler's (90°)
High Fowler's position maximizes diaphragmatic excursion and lung expansion, relieving dyspnea.
Question 5: The nurse is about to administer a medication and the patient states, 'That pill looks different than usual.' What is the nurse's priority action?
- Reassure the patient and administer the medication
- Document the patient's concern and proceed
- Hold the medication and verify the order (Correct answer)
- Ask the charge nurse to administer it instead
Correct answer: Hold the medication and verify the order
Patient statements about medication appearance are a safety cue; the nurse must hold and verify before administering.
Question 6: A nurse is teaching a patient about diaphragmatic breathing. Which instruction is correct?
- Breathe rapidly and shallowly to maximize oxygen intake
- Place one hand on the chest and one on the abdomen; the abdomen should rise more (Correct answer)
- Inhale through the mouth and exhale through the nose
- Hold each breath for at least 10 seconds before exhaling
Correct answer: Place one hand on the chest and one on the abdomen; the abdomen should rise more
In diaphragmatic breathing, abdominal rise should predominate over chest rise, indicating proper use of the diaphragm.
Question 7: Which finding indicates that a patient's nasogastric tube is correctly placed in the stomach?
- Aspiration of clear fluid with a pH of 7.4
- Aspiration of gastric contents with a pH of 1–4 (Correct answer)
- Air bubbling when the tube is placed in water
- The patient is able to speak clearly
Correct answer: Aspiration of gastric contents with a pH of 1–4
Gastric aspirate with a pH of 1–4 confirms correct placement in the stomach before administering feedings.
BSN Fundamentals of Nursing 2
A nurse is preparing to perform a sterile dressing change.
Which action would contaminate the sterile field?