BSN206 Exam 4 Actual Exam Style V3 |
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is caring for a patient who is 2 hours postoperative following abdominal surgery.
The patient’s oxygen saturation is 89% on room air. Which action should the nurse take first?
A. Elevate the head of the bed to a high-Fowler’s position.
B. Encourage the patient to use the incentive spirometer.
C. Administer oxygen via nasal cannula at 2L/min.
D. Notify the surgeon immediately.
Answer: A
Rationale: Elevating the head of the bed is the first independent nursing intervention to
improve gas exchange by allowing maximum chest expansion. This position reduces the
pressure of the abdominal organs on the diaphragm, facilitating easier breathing. After
positioning, the nurse should then assess the need for supplemental oxygen or further
interventions.
2. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving
oxygen at 2 L/min via nasal cannula. The nurse understands that which of the following is the
primary drive for breathing in this patient?
A. Increased levels of carbon dioxide.
,B. Decreased pH of the cerebrospinal fluid.
C. Decreased levels of oxygen in the blood.
D. Stretch receptors in the alveolar walls.
Answer: C
Rationale: In patients with chronic hypercapnia, such as those with COPD, the central
chemoreceptors become insensitive to high CO2 levels. Therefore, their stimulus to breathe
shifts to low oxygen levels, known as the hypoxic drive. Administering too much oxygen
can potentially suppress this drive and lead to respiratory failure.
3. A nurse is reviewing the arterial blood gas (ABG) results for a patient: pH 7.30, PaCO2 52
mmHg, HCO3 26 mEq/L. Which acid-base imbalance does the nurse identify?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The pH is less than 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which is the respiratory component. Because the PaCO2 is high and the pH is low,
this confirms a respiratory origin for the acidosis. The bicarbonate (HCO3) is within the
normal range, suggesting no compensation has occurred yet.
, 4. Which clinical manifestation should the nurse expect to find in a patient with a serum
potassium level of 2.8 mEq/L?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Muscle weakness and leg cramps
D. Trousseau’s sign
Answer: C
Rationale: Hypokalemia, defined as a potassium level below 3.5 mEq/L, commonly
manifests as muscle weakness, fatigue, and leg cramps. Low potassium levels affect the
electrical conduction of skeletal and cardiac muscles. Other signs include decreased bowel
sounds and potential cardiac arrhythmias such as flattened T waves.
5. A patient is scheduled for an elective surgery. Who is responsible for obtaining the
informed consent?
A. The nurse caring for the patient.
B. The anesthesia provider.
C. The surgeon performing the procedure.
D. The hospital administrator.
Answer: C
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is caring for a patient who is 2 hours postoperative following abdominal surgery.
The patient’s oxygen saturation is 89% on room air. Which action should the nurse take first?
A. Elevate the head of the bed to a high-Fowler’s position.
B. Encourage the patient to use the incentive spirometer.
C. Administer oxygen via nasal cannula at 2L/min.
D. Notify the surgeon immediately.
Answer: A
Rationale: Elevating the head of the bed is the first independent nursing intervention to
improve gas exchange by allowing maximum chest expansion. This position reduces the
pressure of the abdominal organs on the diaphragm, facilitating easier breathing. After
positioning, the nurse should then assess the need for supplemental oxygen or further
interventions.
2. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving
oxygen at 2 L/min via nasal cannula. The nurse understands that which of the following is the
primary drive for breathing in this patient?
A. Increased levels of carbon dioxide.
,B. Decreased pH of the cerebrospinal fluid.
C. Decreased levels of oxygen in the blood.
D. Stretch receptors in the alveolar walls.
Answer: C
Rationale: In patients with chronic hypercapnia, such as those with COPD, the central
chemoreceptors become insensitive to high CO2 levels. Therefore, their stimulus to breathe
shifts to low oxygen levels, known as the hypoxic drive. Administering too much oxygen
can potentially suppress this drive and lead to respiratory failure.
3. A nurse is reviewing the arterial blood gas (ABG) results for a patient: pH 7.30, PaCO2 52
mmHg, HCO3 26 mEq/L. Which acid-base imbalance does the nurse identify?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The pH is less than 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which is the respiratory component. Because the PaCO2 is high and the pH is low,
this confirms a respiratory origin for the acidosis. The bicarbonate (HCO3) is within the
normal range, suggesting no compensation has occurred yet.
, 4. Which clinical manifestation should the nurse expect to find in a patient with a serum
potassium level of 2.8 mEq/L?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Muscle weakness and leg cramps
D. Trousseau’s sign
Answer: C
Rationale: Hypokalemia, defined as a potassium level below 3.5 mEq/L, commonly
manifests as muscle weakness, fatigue, and leg cramps. Low potassium levels affect the
electrical conduction of skeletal and cardiac muscles. Other signs include decreased bowel
sounds and potential cardiac arrhythmias such as flattened T waves.
5. A patient is scheduled for an elective surgery. Who is responsible for obtaining the
informed consent?
A. The nurse caring for the patient.
B. The anesthesia provider.
C. The surgeon performing the procedure.
D. The hospital administrator.
Answer: C
