NUR160/NUR 160 Exam 3 V3 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A practical nurse (PN) is caring for a client with a potassium level of 2.8 mEq/L. Which
clinical manifestation should the PN report to the healthcare provider immediately?
A. Hyperactive bowel sounds
B. Muscle weakness and leg cramps
C. Rapid, deep respirations
D. Increased urine output
Correct Answer: B
Rationale: Hypokalemia is characterized by a serum potassium level below 3.5 mEq/L and
frequently presents with neuromuscular symptoms. Muscle weakness and leg cramps are
classic signs of low potassium affecting muscle contraction. The nurse must monitor for
cardiac dysrhythmias as these are life-threatening complications of this electrolyte
imbalance.
2. Which intervention is most appropriate for a PN to implement when caring for a client who
is experiencing a panic-level of anxiety?
A. Provide detailed education about coping mechanisms
,B. Leave the client alone to allow for private reflection
C. Ask the client to explain the cause of their anxiety
D. Speak in short, simple sentences and remain with the client
Correct Answer: D
Rationale: During a panic attack, a client’s ability to process information is severely
diminished. The nurse should use simple language and maintain a calm presence to ensure
safety and provide a sense of security. Encouraging deep breathing or detailed explanations
is ineffective until the client’s anxiety level decreases to a moderate or mild stage.
3. A client is diagnosed with a stage 3 pressure injury on the sacrum. What description best
fits this wound stage?
A. Non-blanchable erythema of intact skin
B. Partial-thickness loss of dermis presenting as a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone or tendon
Correct Answer: C
Rationale: A stage 3 pressure injury involves full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed. Slough or eschar may be
present but does not obscure the depth of tissue loss. This differs from stage 4, which
involves deeper structures like muscle or bone.
, 4. A PN is teaching a client about a clear liquid diet. Which food item should the PN instruct
the client to avoid?
A. Apple juice
B. Chicken broth
C. Vanilla pudding
D. Gelatin
Correct Answer: C
Rationale: A clear liquid diet consists of fluids that are transparent and liquid at room
temperature. Vanilla pudding is considered a full liquid because it contains dairy and is not
transparent. The PN must ensure the client understands that clear liquids must leave
minimal residue in the gastrointestinal tract.
5. A client with schizophrenia is hearing voices telling them that the food is poisoned. How
should the PN respond using therapeutic communication?
A. The food is not poisoned; I ate the same thing for lunch.
B. Why do you think someone would want to poison your food?
C. I do not hear the voices, but I understand that they are real to you.
D. You should stop listening to those voices and try to eat.
Correct Answer: C
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A practical nurse (PN) is caring for a client with a potassium level of 2.8 mEq/L. Which
clinical manifestation should the PN report to the healthcare provider immediately?
A. Hyperactive bowel sounds
B. Muscle weakness and leg cramps
C. Rapid, deep respirations
D. Increased urine output
Correct Answer: B
Rationale: Hypokalemia is characterized by a serum potassium level below 3.5 mEq/L and
frequently presents with neuromuscular symptoms. Muscle weakness and leg cramps are
classic signs of low potassium affecting muscle contraction. The nurse must monitor for
cardiac dysrhythmias as these are life-threatening complications of this electrolyte
imbalance.
2. Which intervention is most appropriate for a PN to implement when caring for a client who
is experiencing a panic-level of anxiety?
A. Provide detailed education about coping mechanisms
,B. Leave the client alone to allow for private reflection
C. Ask the client to explain the cause of their anxiety
D. Speak in short, simple sentences and remain with the client
Correct Answer: D
Rationale: During a panic attack, a client’s ability to process information is severely
diminished. The nurse should use simple language and maintain a calm presence to ensure
safety and provide a sense of security. Encouraging deep breathing or detailed explanations
is ineffective until the client’s anxiety level decreases to a moderate or mild stage.
3. A client is diagnosed with a stage 3 pressure injury on the sacrum. What description best
fits this wound stage?
A. Non-blanchable erythema of intact skin
B. Partial-thickness loss of dermis presenting as a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone or tendon
Correct Answer: C
Rationale: A stage 3 pressure injury involves full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed. Slough or eschar may be
present but does not obscure the depth of tissue loss. This differs from stage 4, which
involves deeper structures like muscle or bone.
, 4. A PN is teaching a client about a clear liquid diet. Which food item should the PN instruct
the client to avoid?
A. Apple juice
B. Chicken broth
C. Vanilla pudding
D. Gelatin
Correct Answer: C
Rationale: A clear liquid diet consists of fluids that are transparent and liquid at room
temperature. Vanilla pudding is considered a full liquid because it contains dairy and is not
transparent. The PN must ensure the client understands that clear liquids must leave
minimal residue in the gastrointestinal tract.
5. A client with schizophrenia is hearing voices telling them that the food is poisoned. How
should the PN respond using therapeutic communication?
A. The food is not poisoned; I ate the same thing for lunch.
B. Why do you think someone would want to poison your food?
C. I do not hear the voices, but I understand that they are real to you.
D. You should stop listening to those voices and try to eat.
Correct Answer: C
