EDIUG YDUTS • 2 MAXE
Nursing Fundamentals
NURS School of Nursing — Exam 2 Study Guide
P A I N · O X Y G E N A T I O N · E L E C T R O LY T E S · W O U N D S · S L E E P · M O B I L I T Y
EXAM 2
Nursing Fundamentals — Exam 2 Study Guide
CO M P R E H E N S I V E R E V I E W : PA I N , OX YG E N AT I O N , F LU I D S / E L E C T R O LYT E S , W O U N D S , S L E E P &
SENSORY
INSTITUTION School of Nursing COURSE CODE NURS-FUND-EXAM2
PROGRAM Nursing — ADN / BSN Pathway ACADEMIC YEAR
EXAM TITLE Nursing Fundamentals Exam 2 TOTAL QUESTIONS 65+ Comprehensive Questions
COURSE TITLE Nursing Fundamentals FORMAT Multiple Choice / Definition / Select All
That Apply
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise indicated.
▸ Questions cover nursing diagnoses with interventions, vital signs, oxygenation, fluid/electrolytes, wound care, sleep disorders,
sensory deficits, pain management, blood transfusion, and ABG interpretation.
▸ Verified answers with detailed rationales are provided for comprehensive exam preparation.
▸ Pay close attention to electrolyte imbalance signs/symptoms, pressure injury staging, and the differences between types of
wound healing.
PAIN, OXYGENATION, ELECTROLYTES, WOUNDS, SLEEP & SENSORY Questions 1 – 65+
1. What are the priority nursing interventions for a patient with the nursing diagnosis of acute pain?
A. Ignore the pain and focus on other problems.
B. Identify pain source using OLDCART, set pain management goals, administer analgesics as prescribed, reassess using
pain scale 30 minutes after medication, and evaluate effectiveness.
C. Only provide non-pharmacological interventions.
D. Wait until the patient requests medication before treating.
CORRECT ANSWER B — Identify source (OLDCART), set goals, administer analgesics, reassess 30 min post-med, evaluate
RATIONALE Acute pain management follows the nursing process: Assessment using OLDCART (Onset, Location, Duration,
Characteristics, Aggravating factors, Relieving factors, Treatment). Goal: reduce pain to a functional level (not
necessarily zero). Pharmacological interventions: administer prescribed analgesics — use the WHO analgesic
ladder (non-opioid → weak opioid → strong opioid). Always reassess pain 30 minutes after IV medication, 60
minutes after oral medication. Non-pharmacological: positioning, ice/heat, relaxation, distraction. Document
pain score, intervention, and response. Unrelieved pain causes systemic stress response: increased cortisol,
catecholamines; cardiovascular strain; impaired wound healing; and increased risk of chronic pain. Pain is the
"fifth vital sign" and must be assessed and treated promptly.
, 2. What are the priority nursing interventions for a patient with impaired gas exchange?
A. Position the patient flat to promote rest.
B. Monitor oxygen saturation, position in Fowler's/semi-Fowler's, administer oxygen as prescribed, administer
bronchodilators/expectorants, and encourage coughing to expectorate secretions.
C. Restrict all fluids.
D. Encourage the patient to avoid coughing.
CORRECT ANSWER B — Monitor O₂ sat, Fowler's position, O₂ therapy, bronchodilators/expectorants, encourage
productive cough
RATIONALE Impaired gas exchange occurs when there is excess or deficit in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane. Priority interventions address the ABCs (Airway, Breathing,
Circulation): (1) Monitor oxygen saturation continuously — normal SpO₂ ≥95% (COPD patients may have
baseline 88-92%); (2) Position in Fowler's (45-60°) or semi-Fowler's (30°) to maximize diaphragmatic excursion
and lung expansion; (3) Administer supplemental oxygen as prescribed to maintain target SpO₂; (4)
Administer bronchodilators (albuterol) to open airways; (5) Administer expectorants (guaifenesin) or
mucolytics to thin secretions; (6) Encourage deep breathing and controlled coughing to mobilize and
expectorate secretions. Goal: patient will maintain SpO₂ ≥95%, clear breath sounds, and cough productively
with ease.
3. What is the difference between essential (primary) hypertension and secondary hypertension?
A. They are the same condition.
B. Essential/primary hypertension has no identifiable cause and develops gradually over years. Secondary
hypertension is caused by an underlying medical condition (renal disease, endocrine disorders, medications).
C. Essential hypertension is always more severe.
D. Secondary hypertension does not require treatment.
CORRECT ANSWER B — Essential (primary): no identifiable cause, gradual. Secondary: caused by underlying condition
RATIONALE Essential (primary) hypertension accounts for 90-95% of cases and develops over years with no single
identifiable cause — risk factors include age, family history, obesity, high sodium intake, physical inactivity,
and stress. Secondary hypertension has an identifiable underlying cause: renal artery stenosis, chronic kidney
disease, hyperaldosteronism, pheochromocytoma, Cushing's syndrome, thyroid disorders, coarctation of the
aorta, medications (oral contraceptives, NSAIDs, decongestants), and obstructive sleep apnea. Treating the
underlying cause may resolve secondary hypertension. Diagnosis requires ≥2 elevated readings on ≥2
separate occasions. Normal BP: <120/<80; Elevated: 120-129/<80; Stage 1 HTN: 130-139/80-89; Stage 2 HTN:
≥140/≥90. Nursing interventions: teach low-sodium diet, encourage aerobic exercise, teach home BP
monitoring with return demonstration, review medication side effects (beta-blockers — bradycardia, fatigue;
ACE inhibitors — dry cough, angioedema).
Nursing Fundamentals
NURS School of Nursing — Exam 2 Study Guide
P A I N · O X Y G E N A T I O N · E L E C T R O LY T E S · W O U N D S · S L E E P · M O B I L I T Y
EXAM 2
Nursing Fundamentals — Exam 2 Study Guide
CO M P R E H E N S I V E R E V I E W : PA I N , OX YG E N AT I O N , F LU I D S / E L E C T R O LYT E S , W O U N D S , S L E E P &
SENSORY
INSTITUTION School of Nursing COURSE CODE NURS-FUND-EXAM2
PROGRAM Nursing — ADN / BSN Pathway ACADEMIC YEAR
EXAM TITLE Nursing Fundamentals Exam 2 TOTAL QUESTIONS 65+ Comprehensive Questions
COURSE TITLE Nursing Fundamentals FORMAT Multiple Choice / Definition / Select All
That Apply
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise indicated.
▸ Questions cover nursing diagnoses with interventions, vital signs, oxygenation, fluid/electrolytes, wound care, sleep disorders,
sensory deficits, pain management, blood transfusion, and ABG interpretation.
▸ Verified answers with detailed rationales are provided for comprehensive exam preparation.
▸ Pay close attention to electrolyte imbalance signs/symptoms, pressure injury staging, and the differences between types of
wound healing.
PAIN, OXYGENATION, ELECTROLYTES, WOUNDS, SLEEP & SENSORY Questions 1 – 65+
1. What are the priority nursing interventions for a patient with the nursing diagnosis of acute pain?
A. Ignore the pain and focus on other problems.
B. Identify pain source using OLDCART, set pain management goals, administer analgesics as prescribed, reassess using
pain scale 30 minutes after medication, and evaluate effectiveness.
C. Only provide non-pharmacological interventions.
D. Wait until the patient requests medication before treating.
CORRECT ANSWER B — Identify source (OLDCART), set goals, administer analgesics, reassess 30 min post-med, evaluate
RATIONALE Acute pain management follows the nursing process: Assessment using OLDCART (Onset, Location, Duration,
Characteristics, Aggravating factors, Relieving factors, Treatment). Goal: reduce pain to a functional level (not
necessarily zero). Pharmacological interventions: administer prescribed analgesics — use the WHO analgesic
ladder (non-opioid → weak opioid → strong opioid). Always reassess pain 30 minutes after IV medication, 60
minutes after oral medication. Non-pharmacological: positioning, ice/heat, relaxation, distraction. Document
pain score, intervention, and response. Unrelieved pain causes systemic stress response: increased cortisol,
catecholamines; cardiovascular strain; impaired wound healing; and increased risk of chronic pain. Pain is the
"fifth vital sign" and must be assessed and treated promptly.
, 2. What are the priority nursing interventions for a patient with impaired gas exchange?
A. Position the patient flat to promote rest.
B. Monitor oxygen saturation, position in Fowler's/semi-Fowler's, administer oxygen as prescribed, administer
bronchodilators/expectorants, and encourage coughing to expectorate secretions.
C. Restrict all fluids.
D. Encourage the patient to avoid coughing.
CORRECT ANSWER B — Monitor O₂ sat, Fowler's position, O₂ therapy, bronchodilators/expectorants, encourage
productive cough
RATIONALE Impaired gas exchange occurs when there is excess or deficit in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane. Priority interventions address the ABCs (Airway, Breathing,
Circulation): (1) Monitor oxygen saturation continuously — normal SpO₂ ≥95% (COPD patients may have
baseline 88-92%); (2) Position in Fowler's (45-60°) or semi-Fowler's (30°) to maximize diaphragmatic excursion
and lung expansion; (3) Administer supplemental oxygen as prescribed to maintain target SpO₂; (4)
Administer bronchodilators (albuterol) to open airways; (5) Administer expectorants (guaifenesin) or
mucolytics to thin secretions; (6) Encourage deep breathing and controlled coughing to mobilize and
expectorate secretions. Goal: patient will maintain SpO₂ ≥95%, clear breath sounds, and cough productively
with ease.
3. What is the difference between essential (primary) hypertension and secondary hypertension?
A. They are the same condition.
B. Essential/primary hypertension has no identifiable cause and develops gradually over years. Secondary
hypertension is caused by an underlying medical condition (renal disease, endocrine disorders, medications).
C. Essential hypertension is always more severe.
D. Secondary hypertension does not require treatment.
CORRECT ANSWER B — Essential (primary): no identifiable cause, gradual. Secondary: caused by underlying condition
RATIONALE Essential (primary) hypertension accounts for 90-95% of cases and develops over years with no single
identifiable cause — risk factors include age, family history, obesity, high sodium intake, physical inactivity,
and stress. Secondary hypertension has an identifiable underlying cause: renal artery stenosis, chronic kidney
disease, hyperaldosteronism, pheochromocytoma, Cushing's syndrome, thyroid disorders, coarctation of the
aorta, medications (oral contraceptives, NSAIDs, decongestants), and obstructive sleep apnea. Treating the
underlying cause may resolve secondary hypertension. Diagnosis requires ≥2 elevated readings on ≥2
separate occasions. Normal BP: <120/<80; Elevated: 120-129/<80; Stage 1 HTN: 130-139/80-89; Stage 2 HTN:
≥140/≥90. Nursing interventions: teach low-sodium diet, encourage aerobic exercise, teach home BP
monitoring with return demonstration, review medication side effects (beta-blockers — bradycardia, fatigue;
ACE inhibitors — dry cough, angioedema).
