NUR160/NUR 160 Final Exam V3 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing an intravenous (IV) site and observes coolness of the skin, pallor, and
edema at the insertion site. Which action should the nurse take first?
A. Apply a warm compress to the site immediately.
B. Stop the infusion and remove the IV catheter.
C. Slow the infusion rate to a keep-vein-open status.
D. Flush the catheter with 0.9% sodium chloride.
Correct Answer: B
Rationale: Coolness, pallor, and edema are classic signs of IV infiltration, which occurs
when non-vesicant fluid enters the subcutaneous tissue. The priority intervention is to stop
the infusion and remove the catheter to prevent further tissue damage. After removal, the
nurse should elevate the extremity and document the findings according to facility policy.
2. A client is scheduled for surgery and has just received a pre-operative sedative. What is the
nurse’s priority safety intervention?
A. Raise the side rails and place the call light within reach.
B. Obtain the signed surgical consent form.
,C. Encourage the client to void one last time.
D. Review the client’s pre-operative teaching.
Correct Answer: A
Rationale: Once a sedative is administered, the client is at an increased risk for falls and
injury due to altered level of consciousness. The nurse must ensure the side rails are up
and the call light is accessible to promote safety. All other tasks, such as signing consent or
voiding, should have been completed prior to medication administration.
3. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse monitor for?
A. Hyperactive bowel sounds
B. Peaked T-waves on an ECG
C. Numbness and tingling in the extremities
D. Muscle weakness and cardiac dysrhythmias
Correct Answer: D
Rationale: A potassium level of 2.8 mEq/L indicates hypokalemia, which significantly
affects neuromuscular and cardiac function. Muscle weakness, cramping, and life-
threatening dysrhythmias are primary concerns for these patients. The nurse must monitor
the ECG for changes such as flattened T-waves or the presence of U-waves.
, 4. A practical nurse (PN) is assigned to care for a client who is 24 hours post-operative. Which
finding requires immediate notification of the registered nurse or surgeon?
A. Absent bowel sounds in all four quadrants
B. Reported pain level of 5 on a scale of 0 to 10
C. Small amount of serosanguineous drainage on the dressing
D. Urine output of 20 mL over the last hour
Correct Answer: D
Rationale: Urine output less than 30 mL per hour indicates poor renal perfusion or
potential shock and requires immediate intervention. While absent bowel sounds are
common immediately post-op, they should be monitored but do not take precedence over
low urinary output. Serosanguineous drainage is an expected finding within the first 24 to
48 hours following surgery.
5. The nurse is preparing to administer an intramuscular injection into the ventrogluteal site.
Which landmark should the nurse use to locate this site?
A. The greater trochanter and the anterior superior iliac spine
B. The acromion process
C. The vastus lateralis muscle
D. The posterior superior iliac spine
Correct Answer: A
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing an intravenous (IV) site and observes coolness of the skin, pallor, and
edema at the insertion site. Which action should the nurse take first?
A. Apply a warm compress to the site immediately.
B. Stop the infusion and remove the IV catheter.
C. Slow the infusion rate to a keep-vein-open status.
D. Flush the catheter with 0.9% sodium chloride.
Correct Answer: B
Rationale: Coolness, pallor, and edema are classic signs of IV infiltration, which occurs
when non-vesicant fluid enters the subcutaneous tissue. The priority intervention is to stop
the infusion and remove the catheter to prevent further tissue damage. After removal, the
nurse should elevate the extremity and document the findings according to facility policy.
2. A client is scheduled for surgery and has just received a pre-operative sedative. What is the
nurse’s priority safety intervention?
A. Raise the side rails and place the call light within reach.
B. Obtain the signed surgical consent form.
,C. Encourage the client to void one last time.
D. Review the client’s pre-operative teaching.
Correct Answer: A
Rationale: Once a sedative is administered, the client is at an increased risk for falls and
injury due to altered level of consciousness. The nurse must ensure the side rails are up
and the call light is accessible to promote safety. All other tasks, such as signing consent or
voiding, should have been completed prior to medication administration.
3. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse monitor for?
A. Hyperactive bowel sounds
B. Peaked T-waves on an ECG
C. Numbness and tingling in the extremities
D. Muscle weakness and cardiac dysrhythmias
Correct Answer: D
Rationale: A potassium level of 2.8 mEq/L indicates hypokalemia, which significantly
affects neuromuscular and cardiac function. Muscle weakness, cramping, and life-
threatening dysrhythmias are primary concerns for these patients. The nurse must monitor
the ECG for changes such as flattened T-waves or the presence of U-waves.
, 4. A practical nurse (PN) is assigned to care for a client who is 24 hours post-operative. Which
finding requires immediate notification of the registered nurse or surgeon?
A. Absent bowel sounds in all four quadrants
B. Reported pain level of 5 on a scale of 0 to 10
C. Small amount of serosanguineous drainage on the dressing
D. Urine output of 20 mL over the last hour
Correct Answer: D
Rationale: Urine output less than 30 mL per hour indicates poor renal perfusion or
potential shock and requires immediate intervention. While absent bowel sounds are
common immediately post-op, they should be monitored but do not take precedence over
low urinary output. Serosanguineous drainage is an expected finding within the first 24 to
48 hours following surgery.
5. The nurse is preparing to administer an intramuscular injection into the ventrogluteal site.
Which landmark should the nurse use to locate this site?
A. The greater trochanter and the anterior superior iliac spine
B. The acromion process
C. The vastus lateralis muscle
D. The posterior superior iliac spine
Correct Answer: A
