BSN 346 | BSN346 Exam 1: Concepts of Nursing III
Updated and Latest Questions and Correct
Answers with Rationale - Nightingale College
1. A nurse is caring for a patient admitted with acute respiratory distress syndrome (ARDS).
Which assessment finding is most critical for the nurse to report to the provider immediately?
A. Oxygen saturation of 92% on 10L via non-rebreather mask.
B. Blood pressure of 110/70 mmHg.
C. Crackles heard in the bilateral lung bases.
D. PaO2/FiO2 ratio of 150.
Correct Answer: D
Expert Explanation: A PaO2/FiO2 ratio below 200 indicates severe hypoxemia and
significant pulmonary shunt, requiring urgent intervention. This finding demonstrates that
despite high oxygen delivery, the patient’s gas exchange is severely compromised. Oxygen
saturation of 92% is acceptable for many patients but does not tell the whole clinical
picture in ARDS. Blood pressure is within normal limits, so it is not the highest priority.
Crackles are expected in ARDS and, while important, do not indicate the severity of the
shunt as directly as the P/F ratio.
2. A patient with Type 1 Diabetes is found unconscious and clammy. Which is the nurse’s first
priority action?
A. Administer 1 mg of glucagon subcutaneously.
B. Check the patient’s blood glucose level.
C. Notify the healthcare provider immediately.
D. Give the patient a glass of orange juice.
Correct Answer: A
Expert Explanation: In an unconscious patient suspected of hypoglycemia, safety and
immediate glucose restoration are paramount. The patient cannot swallow, making oral
fluids like orange juice a significant aspiration risk. While checking blood glucose is
standard, the priority in an emergency with an unconscious patient is to reverse potential
hypoglycemia first. Glucagon is the appropriate emergency intervention for a patient who
is unconscious or cannot swallow. Following administration, the nurse would then confirm
the level and notify the provider of the event.
3. A nurse is caring for a patient who just underwent a total hip arthroplasty. Which action
should the nurse take to prevent dislocation of the new prosthesis?
A. Keep the patient’s legs adducted at all times.
,B. Encourage the patient to cross their legs while sitting.
C. Instruct the patient to bend at the waist to put on socks.
D. Use an abduction pillow between the patient’s legs.
Correct Answer: D
Expert Explanation: Following a total hip replacement, maintaining proper alignment is
essential to prevent surgical failure. Using an abduction pillow keeps the operative leg in a
neutral or slightly abducted position. Adduction or crossing the legs increases the risk of
the femoral head slipping out of the acetabular cup. Bending more than 90 degrees at the
waist is also contraindicated as it stresses the joint capsule. Consistent patient education
and physical barriers like pillows are key evidence-based interventions for safety.
4. Which clinical manifestation would the nurse anticipate in a patient experiencing
autonomic dysreflexia following a spinal cord injury at T6?
A. Severe hypotension and tachycardia.
B. Excessive sweating below the level of injury.
C. Pale, cool skin above the level of injury.
D. Sudden headache and hypertension.
Correct Answer: D
Expert Explanation: Autonomic dysreflexia is a medical emergency characterized by a
massive sympathetic response to a stimulus below the injury level. This results in severe,
sudden hypertension and a pounding headache due to cerebral vasodilation. Below the
level of injury, the nurse would see pale and cool skin due to vasoconstriction. Above the
injury, flushing and sweating are common as the body attempts to compensate. Immediate
action is required to identify and remove the noxious stimulus, such as a full bladder or
bowel.
5. A patient with chronic kidney disease (CKD) has a serum potassium level of 6.5 mEq/L.
Which medication should the nurse expect to administer for immediate cardiac protection?
A. Calcium gluconate.
B. Sodium polystyrene sulfonate (Kayexalate).
C. Furosemide (Lasix).
D. Regular insulin and 50% Dextrose.
Correct Answer: A
Expert Explanation: Hyperkalemia poses an immediate risk of lethal cardiac arrhythmias,
such as ventricular fibrillation. Calcium gluconate is administered to stabilize the
myocardial cell membrane and protect the heart from the effects of high potassium. While
, insulin and dextrose help shift potassium into the cells, they do not stabilize the heart
directly. Sodium polystyrene sulfonate is used for the actual removal of potassium but
takes much longer to act. Furosemide helps excrete potassium but may not be effective if
the patient’s renal function is significantly impaired.
6. The nurse is prioritizing care for four patients. Which patient should the nurse assess first?
A. A patient with a history of heart failure complaining of peripheral edema.
B. A patient with pneumonia who has an oxygen saturation of 93% on room air.
C. A patient 2 hours post-op from a thyroidectomy with a new onset of hoarseness.
D. A patient with end-stage renal disease waiting for scheduled dialysis.
Correct Answer: C
Expert Explanation: Post-thyroidectomy hoarseness or stridor can indicate laryngeal
nerve damage or impending airway obstruction from edema or a hematoma. Airway
management is always the highest priority in the ABC framework of nursing care.
Peripheral edema in heart failure is common and not immediately life-threatening. Oxygen
saturation of 93% is relatively stable for a pneumonia patient. Patients waiting for dialysis
are generally stable unless they present with acute respiratory distress from fluid overload.
7. A patient is receiving a blood transfusion and begins to complain of back pain and chills.
What is the nurse’s first action?
A. Stop the transfusion immediately.
B. Notify the blood bank and healthcare provider.
C. Slow the rate of the transfusion.
D. Administer diphenhydramine as ordered.
Correct Answer: A
Expert Explanation: Back pain and chills during a blood transfusion are classic signs of a
hemolytic reaction, which can be fatal. The immediate nursing priority is to stop the
transfusion to prevent further exposure to the incompatible blood. After stopping the
infusion, the nurse should maintain IV access with normal saline using new tubing. The
provider and blood bank should be notified only after the infusion has been stopped.
Slowing the rate or giving medications without stopping the transfusion would further
endanger the patient.
8. A patient with cirrhosis and ascites is experiencing shortness of breath. Which position
should the nurse place the patient in to promote comfort?
A. Supine with legs elevated.
B. High-Fowler’s position.
C. Sims’ position.
Updated and Latest Questions and Correct
Answers with Rationale - Nightingale College
1. A nurse is caring for a patient admitted with acute respiratory distress syndrome (ARDS).
Which assessment finding is most critical for the nurse to report to the provider immediately?
A. Oxygen saturation of 92% on 10L via non-rebreather mask.
B. Blood pressure of 110/70 mmHg.
C. Crackles heard in the bilateral lung bases.
D. PaO2/FiO2 ratio of 150.
Correct Answer: D
Expert Explanation: A PaO2/FiO2 ratio below 200 indicates severe hypoxemia and
significant pulmonary shunt, requiring urgent intervention. This finding demonstrates that
despite high oxygen delivery, the patient’s gas exchange is severely compromised. Oxygen
saturation of 92% is acceptable for many patients but does not tell the whole clinical
picture in ARDS. Blood pressure is within normal limits, so it is not the highest priority.
Crackles are expected in ARDS and, while important, do not indicate the severity of the
shunt as directly as the P/F ratio.
2. A patient with Type 1 Diabetes is found unconscious and clammy. Which is the nurse’s first
priority action?
A. Administer 1 mg of glucagon subcutaneously.
B. Check the patient’s blood glucose level.
C. Notify the healthcare provider immediately.
D. Give the patient a glass of orange juice.
Correct Answer: A
Expert Explanation: In an unconscious patient suspected of hypoglycemia, safety and
immediate glucose restoration are paramount. The patient cannot swallow, making oral
fluids like orange juice a significant aspiration risk. While checking blood glucose is
standard, the priority in an emergency with an unconscious patient is to reverse potential
hypoglycemia first. Glucagon is the appropriate emergency intervention for a patient who
is unconscious or cannot swallow. Following administration, the nurse would then confirm
the level and notify the provider of the event.
3. A nurse is caring for a patient who just underwent a total hip arthroplasty. Which action
should the nurse take to prevent dislocation of the new prosthesis?
A. Keep the patient’s legs adducted at all times.
,B. Encourage the patient to cross their legs while sitting.
C. Instruct the patient to bend at the waist to put on socks.
D. Use an abduction pillow between the patient’s legs.
Correct Answer: D
Expert Explanation: Following a total hip replacement, maintaining proper alignment is
essential to prevent surgical failure. Using an abduction pillow keeps the operative leg in a
neutral or slightly abducted position. Adduction or crossing the legs increases the risk of
the femoral head slipping out of the acetabular cup. Bending more than 90 degrees at the
waist is also contraindicated as it stresses the joint capsule. Consistent patient education
and physical barriers like pillows are key evidence-based interventions for safety.
4. Which clinical manifestation would the nurse anticipate in a patient experiencing
autonomic dysreflexia following a spinal cord injury at T6?
A. Severe hypotension and tachycardia.
B. Excessive sweating below the level of injury.
C. Pale, cool skin above the level of injury.
D. Sudden headache and hypertension.
Correct Answer: D
Expert Explanation: Autonomic dysreflexia is a medical emergency characterized by a
massive sympathetic response to a stimulus below the injury level. This results in severe,
sudden hypertension and a pounding headache due to cerebral vasodilation. Below the
level of injury, the nurse would see pale and cool skin due to vasoconstriction. Above the
injury, flushing and sweating are common as the body attempts to compensate. Immediate
action is required to identify and remove the noxious stimulus, such as a full bladder or
bowel.
5. A patient with chronic kidney disease (CKD) has a serum potassium level of 6.5 mEq/L.
Which medication should the nurse expect to administer for immediate cardiac protection?
A. Calcium gluconate.
B. Sodium polystyrene sulfonate (Kayexalate).
C. Furosemide (Lasix).
D. Regular insulin and 50% Dextrose.
Correct Answer: A
Expert Explanation: Hyperkalemia poses an immediate risk of lethal cardiac arrhythmias,
such as ventricular fibrillation. Calcium gluconate is administered to stabilize the
myocardial cell membrane and protect the heart from the effects of high potassium. While
, insulin and dextrose help shift potassium into the cells, they do not stabilize the heart
directly. Sodium polystyrene sulfonate is used for the actual removal of potassium but
takes much longer to act. Furosemide helps excrete potassium but may not be effective if
the patient’s renal function is significantly impaired.
6. The nurse is prioritizing care for four patients. Which patient should the nurse assess first?
A. A patient with a history of heart failure complaining of peripheral edema.
B. A patient with pneumonia who has an oxygen saturation of 93% on room air.
C. A patient 2 hours post-op from a thyroidectomy with a new onset of hoarseness.
D. A patient with end-stage renal disease waiting for scheduled dialysis.
Correct Answer: C
Expert Explanation: Post-thyroidectomy hoarseness or stridor can indicate laryngeal
nerve damage or impending airway obstruction from edema or a hematoma. Airway
management is always the highest priority in the ABC framework of nursing care.
Peripheral edema in heart failure is common and not immediately life-threatening. Oxygen
saturation of 93% is relatively stable for a pneumonia patient. Patients waiting for dialysis
are generally stable unless they present with acute respiratory distress from fluid overload.
7. A patient is receiving a blood transfusion and begins to complain of back pain and chills.
What is the nurse’s first action?
A. Stop the transfusion immediately.
B. Notify the blood bank and healthcare provider.
C. Slow the rate of the transfusion.
D. Administer diphenhydramine as ordered.
Correct Answer: A
Expert Explanation: Back pain and chills during a blood transfusion are classic signs of a
hemolytic reaction, which can be fatal. The immediate nursing priority is to stop the
transfusion to prevent further exposure to the incompatible blood. After stopping the
infusion, the nurse should maintain IV access with normal saline using new tubing. The
provider and blood bank should be notified only after the infusion has been stopped.
Slowing the rate or giving medications without stopping the transfusion would further
endanger the patient.
8. A patient with cirrhosis and ascites is experiencing shortness of breath. Which position
should the nurse place the patient in to promote comfort?
A. Supine with legs elevated.
B. High-Fowler’s position.
C. Sims’ position.
