NUR160/NUR 160 Exam 3 V2 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a patient who has an intravenous (IV) line. The nurse notes that the
site is cool to the touch, swollen, and the infusion rate has slowed. Which complication
should the nurse suspect?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Thrombosis
Correct Answer: B
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue. Common signs include coolness, swelling (edema), and discomfort at
the site. The nurse should immediately stop the infusion and elevate the extremity to
promote fluid reabsorption.
2. Which serum potassium level should the nurse report to the healthcare provider
immediately for a patient receiving a loop diuretic?
A. 3.2 mEq/L
,B. 3.8 mEq/L
C. 4.5 mEq/L
D. 5.1 mEq/L
Correct Answer: A
Rationale: The normal range for serum potassium is 3.5 to 5.0 mEq/L. A value of 3.2
mEq/L indicates hypokalemia, which can lead to life-threatening cardiac dysrhythmias.
Loop diuretics often cause potassium loss, necessitating frequent monitoring and potential
supplementation.
3. A patient is scheduled for an elective surgery. Who is legally responsible for obtaining the
patient’s informed consent and explaining the risks and benefits?
A. The scrub nurse
B. The circulating nurse
C. The surgeon
D. The charge nurse
Correct Answer: C
Rationale: The surgeon or healthcare provider performing the procedure is legally
responsible for obtaining informed consent. The nurse’s role is to witness the signing of the
document and verify that the patient understands the information provided. If the patient
has further questions about the procedure itself, the nurse must contact the surgeon.
, 4. Which of the following is the priority nursing intervention for a patient in the immediate
postoperative period after general anesthesia?
A. Maintaining airway patency
B. Assessing surgical dressing
C. Monitoring urine output
D. Managing postoperative pain
Correct Answer: A
Rationale: Airway management is the highest priority following general anesthesia due to
the risk of respiratory depression and aspiration. The nurse must ensure the patient has an
open airway and adequate gas exchange before addressing other needs. Assessments of the
surgical site and pain management follow once the patient is stable.
5. A nurse is caring for a patient with a suspected urinary tract infection (UTI). Which clinical
manifestation is most commonly seen in elderly patients with a UTI?
A. High fever and chills
B. Hematuria
C. Severe flank pain
D. Confusion and altered mental status
Correct Answer: D
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a patient who has an intravenous (IV) line. The nurse notes that the
site is cool to the touch, swollen, and the infusion rate has slowed. Which complication
should the nurse suspect?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Thrombosis
Correct Answer: B
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue. Common signs include coolness, swelling (edema), and discomfort at
the site. The nurse should immediately stop the infusion and elevate the extremity to
promote fluid reabsorption.
2. Which serum potassium level should the nurse report to the healthcare provider
immediately for a patient receiving a loop diuretic?
A. 3.2 mEq/L
,B. 3.8 mEq/L
C. 4.5 mEq/L
D. 5.1 mEq/L
Correct Answer: A
Rationale: The normal range for serum potassium is 3.5 to 5.0 mEq/L. A value of 3.2
mEq/L indicates hypokalemia, which can lead to life-threatening cardiac dysrhythmias.
Loop diuretics often cause potassium loss, necessitating frequent monitoring and potential
supplementation.
3. A patient is scheduled for an elective surgery. Who is legally responsible for obtaining the
patient’s informed consent and explaining the risks and benefits?
A. The scrub nurse
B. The circulating nurse
C. The surgeon
D. The charge nurse
Correct Answer: C
Rationale: The surgeon or healthcare provider performing the procedure is legally
responsible for obtaining informed consent. The nurse’s role is to witness the signing of the
document and verify that the patient understands the information provided. If the patient
has further questions about the procedure itself, the nurse must contact the surgeon.
, 4. Which of the following is the priority nursing intervention for a patient in the immediate
postoperative period after general anesthesia?
A. Maintaining airway patency
B. Assessing surgical dressing
C. Monitoring urine output
D. Managing postoperative pain
Correct Answer: A
Rationale: Airway management is the highest priority following general anesthesia due to
the risk of respiratory depression and aspiration. The nurse must ensure the patient has an
open airway and adequate gas exchange before addressing other needs. Assessments of the
surgical site and pain management follow once the patient is stable.
5. A nurse is caring for a patient with a suspected urinary tract infection (UTI). Which clinical
manifestation is most commonly seen in elderly patients with a UTI?
A. High fever and chills
B. Hematuria
C. Severe flank pain
D. Confusion and altered mental status
Correct Answer: D
