BSN206 Exam 4 Actual Exam Style V2 |
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is caring for a patient who is experiencing respiratory distress and has an oxygen
saturation of 88%. Which oxygen delivery device should the nurse use to provide the highest
concentration of oxygen?
A. Nonrebreather mask
B. Simple face mask
C. Nasal cannula
D. Venturi mask
Answer: A
Rationale: The nonrebreather mask provides the highest concentration of oxygen,
typically between 60% and 90%. It utilizes a reservoir bag and one-way valves to prevent
the patient from rebreathing exhaled air. This device is the priority choice for patients in
severe respiratory distress requiring high FiO2.
2. Which clinical manifestation should a nurse monitor for in a patient with a potassium level
of 5.8 mEq/L?
A. Hyperactive deep tendon reflexes
,B. Increased bowel sounds
C. Muscle cramps and tetany
D. Tall, peaked T waves on ECG
Answer: D
Rationale: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L.
Tall, peaked T waves are a classic cardiac sign of elevated potassium levels that require
immediate attention. Cardiac monitoring is essential for these patients to prevent life-
threatening arrhythmias or cardiac arrest.
3. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 52 mmHg, and HCO3 25
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Answer: D
Rationale: The pH of 7.31 indicates acidosis since it is below the normal range of 7.35-
7.45. The PaCO2 of 52 mmHg is elevated, which suggests a respiratory cause for the low
pH. Because the HCO3 is within the normal range, this is identified as uncompensated
respiratory acidosis.
, 4. When performing tracheostomy suctioning, what is the maximum amount of time the
nurse should apply suction?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 25 seconds
D. 30 seconds
Answer: A
Rationale: Suctioning should be limited to 10 to 15 seconds to prevent hypoxia and trauma
to the tracheal mucosa. The nurse must allow the patient to recover and hyperoxygenate
between passes if necessary. Prolonged suctioning can lead to significant decreases in
oxygen saturation and cardiac arrhythmias.
5. Which intervention is most appropriate for a patient with a Stage 2 pressure injury on the
coccyx?
A. Apply a wet-to-dry gauze dressing
B. Massage the reddened area
C. Cleanse with hydrogen peroxide
D. Apply a hydrocolloid dressing
Answer: D
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is caring for a patient who is experiencing respiratory distress and has an oxygen
saturation of 88%. Which oxygen delivery device should the nurse use to provide the highest
concentration of oxygen?
A. Nonrebreather mask
B. Simple face mask
C. Nasal cannula
D. Venturi mask
Answer: A
Rationale: The nonrebreather mask provides the highest concentration of oxygen,
typically between 60% and 90%. It utilizes a reservoir bag and one-way valves to prevent
the patient from rebreathing exhaled air. This device is the priority choice for patients in
severe respiratory distress requiring high FiO2.
2. Which clinical manifestation should a nurse monitor for in a patient with a potassium level
of 5.8 mEq/L?
A. Hyperactive deep tendon reflexes
,B. Increased bowel sounds
C. Muscle cramps and tetany
D. Tall, peaked T waves on ECG
Answer: D
Rationale: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L.
Tall, peaked T waves are a classic cardiac sign of elevated potassium levels that require
immediate attention. Cardiac monitoring is essential for these patients to prevent life-
threatening arrhythmias or cardiac arrest.
3. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 52 mmHg, and HCO3 25
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Answer: D
Rationale: The pH of 7.31 indicates acidosis since it is below the normal range of 7.35-
7.45. The PaCO2 of 52 mmHg is elevated, which suggests a respiratory cause for the low
pH. Because the HCO3 is within the normal range, this is identified as uncompensated
respiratory acidosis.
, 4. When performing tracheostomy suctioning, what is the maximum amount of time the
nurse should apply suction?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 25 seconds
D. 30 seconds
Answer: A
Rationale: Suctioning should be limited to 10 to 15 seconds to prevent hypoxia and trauma
to the tracheal mucosa. The nurse must allow the patient to recover and hyperoxygenate
between passes if necessary. Prolonged suctioning can lead to significant decreases in
oxygen saturation and cardiac arrhythmias.
5. Which intervention is most appropriate for a patient with a Stage 2 pressure injury on the
coccyx?
A. Apply a wet-to-dry gauze dressing
B. Massage the reddened area
C. Cleanse with hydrogen peroxide
D. Apply a hydrocolloid dressing
Answer: D
