NUR160/NUR 160 Final Exam V2 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which of the
following interventions should the nurse prioritize?
A. Check the client’s most recent EKG for peaked T waves.
B. Administer a potassium-sparing diuretic as ordered.
C. Encourage the intake of bananas and orange juice.
D. Request a repeat blood draw to verify the results.
Correct Answer: A
Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, poses a
significant risk for cardiac arrhythmias. Peaked T waves and widened QRS complexes are
classic signs of potassium toxicity that require immediate monitoring. Assessing the EKG
allows the nurse to identify life-threatening changes before they progress to cardiac arrest.
2. A client has the following arterial blood gas results: pH 7.30, PaCO2 55 mmHg, and HCO3 24
mEq/L. The nurse identifies this as which acid-base imbalance?
A. Metabolic Acidosis
B. Respiratory Acidosis
,C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Rationale: A pH below 7.35 indicates acidosis, while a PaCO2 above 45 mmHg indicates a
respiratory cause for the imbalance. Since the bicarbonate (HCO3) level is within the
normal range of 22-26 mEq/L, the imbalance is not metabolic. This combination typically
occurs in patients with hypoventilation or obstructive lung diseases like COPD.
3. When caring for a client with Chronic Obstructive Pulmonary Disease (COPD) receiving
oxygen therapy, what is the maximum recommended flow rate to prevent respiratory
depression?
A. 6 L/min via simple face mask
B. 2 L/min via nasal cannula
C. 10 L/min via non-rebreather mask
D. 4 L/min via nasal cannula
Correct Answer: B
Rationale: Clients with COPD often rely on a ‘hypoxic drive’ to stimulate breathing due to
chronic carbon dioxide retention. Administering high levels of oxygen can satisfy this drive
and lead to hypoventilation or apnea. Maintaining a low flow rate, typically 1-2 L/min,
ensures adequate oxygenation without suppressing the respiratory effort.
,4. A nurse is preparing a client for surgery. Which of the following is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the surgical procedure.
B. Ensuring the client understands the alternative treatments available.
C. Witnessing the client’s signature on the consent form.
D. Obtaining the consent if the surgeon is currently unavailable.
Correct Answer: C
Rationale: The primary role of the nurse in the informed consent process is to act as a
witness to the client’s signature. The surgeon is legally responsible for explaining the
procedure, risks, and benefits to the patient. If the nurse notes that the client does not
understand the procedure, the surgeon must be notified to return and provide further
clarification.
5. Which clinical manifestation should the nurse expect to find in a client experiencing
hypoglycemia?
A. Fruity-smelling breath
B. Extreme thirst and polyuria
C. Abdominal pain and Kussmaul respirations
D. Diaphoresis and tremors
Correct Answer: D
, Rationale: Hypoglycemia triggers the sympathetic nervous system, leading to symptoms
such as sweating (diaphoresis), shaking (tremors), and tachycardia. In contrast, fruity
breath and Kussmaul respirations are characteristic of Diabetic Ketoacidosis (DKA), which
involves hyperglycemia. Rapid recognition of these ‘cold and clammy’ symptoms is
essential for prompt glucose administration.
6. A nurse is teaching a client how to use a Metered-Dose Inhaler (MDI). Which instruction is
correct?
A. Exhale deeply, then inhale quickly while pressing the canister.
B. Hold your breath for 10 seconds after inhaling the medication.
C. Wait 10 seconds between puffs of the same medication.
D. Rinse your mouth with water only if using a bronchodilator.
Correct Answer: B
Rationale: Holding the breath for approximately 10 seconds allows the medication to
settle deep into the lung tissue for maximum absorption. Patients should also be instructed
to wait 1-2 minutes between puffs of the same medication to allow the first dose to begin
working. Rinsing the mouth is specifically required after using corticosteroid inhalers to
prevent oral candidiasis (thrush).
7. A client is prescribed Furosemide (Lasix) for heart failure. Which laboratory value should
the nurse monitor most closely?
A. Serum Sodium
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which of the
following interventions should the nurse prioritize?
A. Check the client’s most recent EKG for peaked T waves.
B. Administer a potassium-sparing diuretic as ordered.
C. Encourage the intake of bananas and orange juice.
D. Request a repeat blood draw to verify the results.
Correct Answer: A
Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, poses a
significant risk for cardiac arrhythmias. Peaked T waves and widened QRS complexes are
classic signs of potassium toxicity that require immediate monitoring. Assessing the EKG
allows the nurse to identify life-threatening changes before they progress to cardiac arrest.
2. A client has the following arterial blood gas results: pH 7.30, PaCO2 55 mmHg, and HCO3 24
mEq/L. The nurse identifies this as which acid-base imbalance?
A. Metabolic Acidosis
B. Respiratory Acidosis
,C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Rationale: A pH below 7.35 indicates acidosis, while a PaCO2 above 45 mmHg indicates a
respiratory cause for the imbalance. Since the bicarbonate (HCO3) level is within the
normal range of 22-26 mEq/L, the imbalance is not metabolic. This combination typically
occurs in patients with hypoventilation or obstructive lung diseases like COPD.
3. When caring for a client with Chronic Obstructive Pulmonary Disease (COPD) receiving
oxygen therapy, what is the maximum recommended flow rate to prevent respiratory
depression?
A. 6 L/min via simple face mask
B. 2 L/min via nasal cannula
C. 10 L/min via non-rebreather mask
D. 4 L/min via nasal cannula
Correct Answer: B
Rationale: Clients with COPD often rely on a ‘hypoxic drive’ to stimulate breathing due to
chronic carbon dioxide retention. Administering high levels of oxygen can satisfy this drive
and lead to hypoventilation or apnea. Maintaining a low flow rate, typically 1-2 L/min,
ensures adequate oxygenation without suppressing the respiratory effort.
,4. A nurse is preparing a client for surgery. Which of the following is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the surgical procedure.
B. Ensuring the client understands the alternative treatments available.
C. Witnessing the client’s signature on the consent form.
D. Obtaining the consent if the surgeon is currently unavailable.
Correct Answer: C
Rationale: The primary role of the nurse in the informed consent process is to act as a
witness to the client’s signature. The surgeon is legally responsible for explaining the
procedure, risks, and benefits to the patient. If the nurse notes that the client does not
understand the procedure, the surgeon must be notified to return and provide further
clarification.
5. Which clinical manifestation should the nurse expect to find in a client experiencing
hypoglycemia?
A. Fruity-smelling breath
B. Extreme thirst and polyuria
C. Abdominal pain and Kussmaul respirations
D. Diaphoresis and tremors
Correct Answer: D
, Rationale: Hypoglycemia triggers the sympathetic nervous system, leading to symptoms
such as sweating (diaphoresis), shaking (tremors), and tachycardia. In contrast, fruity
breath and Kussmaul respirations are characteristic of Diabetic Ketoacidosis (DKA), which
involves hyperglycemia. Rapid recognition of these ‘cold and clammy’ symptoms is
essential for prompt glucose administration.
6. A nurse is teaching a client how to use a Metered-Dose Inhaler (MDI). Which instruction is
correct?
A. Exhale deeply, then inhale quickly while pressing the canister.
B. Hold your breath for 10 seconds after inhaling the medication.
C. Wait 10 seconds between puffs of the same medication.
D. Rinse your mouth with water only if using a bronchodilator.
Correct Answer: B
Rationale: Holding the breath for approximately 10 seconds allows the medication to
settle deep into the lung tissue for maximum absorption. Patients should also be instructed
to wait 1-2 minutes between puffs of the same medication to allow the first dose to begin
working. Rinsing the mouth is specifically required after using corticosteroid inhalers to
prevent oral candidiasis (thrush).
7. A client is prescribed Furosemide (Lasix) for heart failure. Which laboratory value should
the nurse monitor most closely?
A. Serum Sodium
