NSG 3130 Fundamental II Assessment (Nursing
Practice II) Exam 2 Latest Updated Rated A+
Question 1
The nurse is assessing a patient’s respiratory status. Which finding requires immediate
intervention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 92%
C. Clear lung sounds bilaterally
D. Symmetrical chest expansion
Rationale: Normal SpO₂ is ≥95%. A value of 92% indicates hypoxemia requiring
intervention.
Question 2
Which nursing action best promotes patient safety during ambulation with a walker?
A. Encourage patient to carry walker
B. Place walker too far ahead
C. Ensure patient steps into walker
D. Allow patient to lean backward
Rationale: Proper technique prevents falls and maintains balance.
Question 3
A patient reports dizziness when standing. What is the priority nursing action?
A. Encourage fluids
B. Assess for orthostatic hypotension
C. Provide snacks
D. Document findings only
Rationale: Dizziness upon standing is a hallmark of orthostatic hypotension;
assessment guides interventions.
Question 4
Which statement indicates effective discharge teaching for a patient with hypertension?
A. “I will stop taking my medication when I feel better.”
B. “I will monitor my blood pressure regularly.”
C. “I will avoid exercise to reduce stress.”
D. “I will increase salt intake for energy.”
Rationale: Ongoing monitoring is essential for hypertension management.
Question 5
During a cognitive assessment, which finding requires further evaluation?
A. Patient recalls three words after 5 minutes
B. Patient forgets recent events
C. Patient knows current date
D. Patient identifies family members
Rationale: Short-term memory loss may indicate cognitive impairment.
,Question 6
Which intervention prevents pressure ulcers in immobile patients?
A. Encourage fluid intake
B. Reposition every 2 hours
C. Provide high-protein snacks only
D. Limit mobility to conserve energy
Rationale: Regular repositioning reduces pressure and promotes circulation.
Question 7
The nurse is teaching a patient about fall prevention at home. Which statement
indicates need for further teaching?
A. “I will remove loose rugs.”
B. “I will keep pathways well lit.”
C. “I will store items on high shelves.”
D. “I will wear supportive shoes.”
Rationale: Storing items high increases risk of falls when reaching.
Question 8
Which nursing action demonstrates proper hand hygiene?
A. Using gloves instead of washing hands
B. Washing hands for at least 20 seconds
C. Rinsing hands quickly under water
D. Applying lotion before patient care
Rationale: Effective hand hygiene requires thorough washing for ≥20 seconds.
Question 9
A patient with COPD is receiving oxygen therapy. Which finding requires immediate
action?
A. SpO₂ 95%
B. Patient reports headache
C. SpO₂ 88%
D. Patient breathing at 20/min
Rationale: Oxygen saturation below 90% indicates hypoxemia requiring intervention.
Question 10
Which nursing intervention promotes sleep hygiene?
A. Encourage caffeine intake before bed
B. Maintain consistent bedtime routine
C. Increase screen time before sleep
D. Provide heavy meals at night
Rationale: Consistency supports circadian rhythm and quality sleep.
Question 11
Which finding indicates effective pain management?
A. Patient reports pain level 8/10
, B. Patient states pain is tolerable at 2/10
C. Patient refuses medication despite pain
D. Patient grimaces during movement
Rationale: Pain relief is effective when patient reports manageable pain.
Question 12
Which nursing action prevents infection in catheterized patients?
A. Maintain closed drainage system
B. Place catheter bag on bed
C. Disconnect tubing frequently
D. Irrigate catheter routinely
Rationale: Closed systems reduce risk of infection.
Question 13
Which patient statement indicates understanding of diabetic foot care?
A. “I will walk barefoot at home.”
B. “I will inspect my feet daily.”
C. “I will trim nails with scissors.”
D. “I will soak feet in hot water.”
Rationale: Daily inspection prevents unnoticed injuries and complications.
Question 14
Which nursing action supports effective communication with hearing-impaired patients?
A. Speak loudly from behind
B. Face patient directly when speaking
C. Use medical jargon
D. Avoid visual aids
Rationale: Direct communication enhances lip-reading and comprehension.
Question 15
Which finding requires immediate intervention in a patient with IV therapy?
A. Site is clean and dry
B. Patient reports burning at site
C. IV fluids infusing at ordered rate
D. Transparent dressing intact
Rationale: Burning may indicate infiltration or phlebitis.
Question 16
Which nursing action promotes patient autonomy?
A. Making decisions for patient
B. Encouraging patient participation in care
C. Ignoring patient preferences
D. Limiting patient choices
Rationale: Autonomy is supported when patients are involved in decisions.
Question 17
Practice II) Exam 2 Latest Updated Rated A+
Question 1
The nurse is assessing a patient’s respiratory status. Which finding requires immediate
intervention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 92%
C. Clear lung sounds bilaterally
D. Symmetrical chest expansion
Rationale: Normal SpO₂ is ≥95%. A value of 92% indicates hypoxemia requiring
intervention.
Question 2
Which nursing action best promotes patient safety during ambulation with a walker?
A. Encourage patient to carry walker
B. Place walker too far ahead
C. Ensure patient steps into walker
D. Allow patient to lean backward
Rationale: Proper technique prevents falls and maintains balance.
Question 3
A patient reports dizziness when standing. What is the priority nursing action?
A. Encourage fluids
B. Assess for orthostatic hypotension
C. Provide snacks
D. Document findings only
Rationale: Dizziness upon standing is a hallmark of orthostatic hypotension;
assessment guides interventions.
Question 4
Which statement indicates effective discharge teaching for a patient with hypertension?
A. “I will stop taking my medication when I feel better.”
B. “I will monitor my blood pressure regularly.”
C. “I will avoid exercise to reduce stress.”
D. “I will increase salt intake for energy.”
Rationale: Ongoing monitoring is essential for hypertension management.
Question 5
During a cognitive assessment, which finding requires further evaluation?
A. Patient recalls three words after 5 minutes
B. Patient forgets recent events
C. Patient knows current date
D. Patient identifies family members
Rationale: Short-term memory loss may indicate cognitive impairment.
,Question 6
Which intervention prevents pressure ulcers in immobile patients?
A. Encourage fluid intake
B. Reposition every 2 hours
C. Provide high-protein snacks only
D. Limit mobility to conserve energy
Rationale: Regular repositioning reduces pressure and promotes circulation.
Question 7
The nurse is teaching a patient about fall prevention at home. Which statement
indicates need for further teaching?
A. “I will remove loose rugs.”
B. “I will keep pathways well lit.”
C. “I will store items on high shelves.”
D. “I will wear supportive shoes.”
Rationale: Storing items high increases risk of falls when reaching.
Question 8
Which nursing action demonstrates proper hand hygiene?
A. Using gloves instead of washing hands
B. Washing hands for at least 20 seconds
C. Rinsing hands quickly under water
D. Applying lotion before patient care
Rationale: Effective hand hygiene requires thorough washing for ≥20 seconds.
Question 9
A patient with COPD is receiving oxygen therapy. Which finding requires immediate
action?
A. SpO₂ 95%
B. Patient reports headache
C. SpO₂ 88%
D. Patient breathing at 20/min
Rationale: Oxygen saturation below 90% indicates hypoxemia requiring intervention.
Question 10
Which nursing intervention promotes sleep hygiene?
A. Encourage caffeine intake before bed
B. Maintain consistent bedtime routine
C. Increase screen time before sleep
D. Provide heavy meals at night
Rationale: Consistency supports circadian rhythm and quality sleep.
Question 11
Which finding indicates effective pain management?
A. Patient reports pain level 8/10
, B. Patient states pain is tolerable at 2/10
C. Patient refuses medication despite pain
D. Patient grimaces during movement
Rationale: Pain relief is effective when patient reports manageable pain.
Question 12
Which nursing action prevents infection in catheterized patients?
A. Maintain closed drainage system
B. Place catheter bag on bed
C. Disconnect tubing frequently
D. Irrigate catheter routinely
Rationale: Closed systems reduce risk of infection.
Question 13
Which patient statement indicates understanding of diabetic foot care?
A. “I will walk barefoot at home.”
B. “I will inspect my feet daily.”
C. “I will trim nails with scissors.”
D. “I will soak feet in hot water.”
Rationale: Daily inspection prevents unnoticed injuries and complications.
Question 14
Which nursing action supports effective communication with hearing-impaired patients?
A. Speak loudly from behind
B. Face patient directly when speaking
C. Use medical jargon
D. Avoid visual aids
Rationale: Direct communication enhances lip-reading and comprehension.
Question 15
Which finding requires immediate intervention in a patient with IV therapy?
A. Site is clean and dry
B. Patient reports burning at site
C. IV fluids infusing at ordered rate
D. Transparent dressing intact
Rationale: Burning may indicate infiltration or phlebitis.
Question 16
Which nursing action promotes patient autonomy?
A. Making decisions for patient
B. Encouraging patient participation in care
C. Ignoring patient preferences
D. Limiting patient choices
Rationale: Autonomy is supported when patients are involved in decisions.
Question 17
