NUR160/NUR 160 Final Exam V1 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is monitoring a client receiving IV fluids for signs of fluid volume overload. Which
assessment finding should the nurse report to the provider immediately?
A. Decreased blood pressure and increased heart rate
B. Flattened neck veins when lying supine
C. Bounding peripheral pulses and crackles in the lungs
D. Weight loss of 1 lb (0.45 kg) over 24 hours
Correct Answer: C
Rationale: Crackles in the lungs and bounding pulses are classic indicators of pulmonary
edema and fluid volume excess. This condition requires rapid intervention to prevent
respiratory distress or cardiac failure. The nurse must document these findings and notify
the healthcare provider for potential diuretic administration.
2. A practical nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which
cardiac rhythm change should the nurse expect to see on the monitor?
A. Tall, peaked T waves
B. Prominent U waves and ST depression
,C. Shortened QT interval
D. Widened QRS complex
Correct Answer: B
Rationale: Hypokalemia, defined as a potassium level below 3.5 mEq/L, typically manifests
as flat or inverted T waves and prominent U waves. Peaked T waves are conversely
associated with hyperkalemia. The nurse must monitor these changes closely as potassium
imbalances significantly increase the risk for lethal arrhythmias.
3. When preparing a client for a surgical procedure, which action by the nurse is essential to
satisfy legal requirements for informed consent?
A. Explaining the risks and benefits of the surgery to the client
B. Witnessing the client’s signature on the consent form
C. Ensuring the client understands the alternative treatments available
D. Obtaining the signature from the next of kin before the client signs
Correct Answer: B
Rationale: The role of the nurse in the consent process is primarily to witness that the
signature is authentic and given voluntarily. It is the surgeon’s responsibility to explain the
procedure, risks, and benefits to the patient. If the nurse discovers the patient does not
understand the procedure, the surgeon must be notified to provide further clarification.
, 4. A nurse is assessing a client’s surgical incision on the second postoperative day and notes
thick, yellow-green drainage. How should the nurse document this finding?
A. Serous drainage
B. Sanguineous drainage
C. Purulent drainage
D. Serosanguineous drainage
Correct Answer: C
Rationale: Purulent drainage is characterized by thick, opaque fluid that may be yellow,
green, or tan, often indicating an infection. Sanguineous drainage is bright red blood, while
serous is clear and watery. Recognizing these differences is vital for the nurse to assess the
healing process and identify complications early.
5. Which nursing intervention is a priority for a client diagnosed with respiratory acidosis?
A. Maintaining a patent airway and improving ventilation
B. Administering sodium bicarbonate intravenously
C. Encouraging the client to breathe into a paper bag
D. Restricting fluid intake to prevent pulmonary congestion
Correct Answer: A
Rationale: Respiratory acidosis is caused by hypoventilation leading to the retention of
carbon dioxide. The primary goal of treatment is to improve gas exchange and clear the
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is monitoring a client receiving IV fluids for signs of fluid volume overload. Which
assessment finding should the nurse report to the provider immediately?
A. Decreased blood pressure and increased heart rate
B. Flattened neck veins when lying supine
C. Bounding peripheral pulses and crackles in the lungs
D. Weight loss of 1 lb (0.45 kg) over 24 hours
Correct Answer: C
Rationale: Crackles in the lungs and bounding pulses are classic indicators of pulmonary
edema and fluid volume excess. This condition requires rapid intervention to prevent
respiratory distress or cardiac failure. The nurse must document these findings and notify
the healthcare provider for potential diuretic administration.
2. A practical nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which
cardiac rhythm change should the nurse expect to see on the monitor?
A. Tall, peaked T waves
B. Prominent U waves and ST depression
,C. Shortened QT interval
D. Widened QRS complex
Correct Answer: B
Rationale: Hypokalemia, defined as a potassium level below 3.5 mEq/L, typically manifests
as flat or inverted T waves and prominent U waves. Peaked T waves are conversely
associated with hyperkalemia. The nurse must monitor these changes closely as potassium
imbalances significantly increase the risk for lethal arrhythmias.
3. When preparing a client for a surgical procedure, which action by the nurse is essential to
satisfy legal requirements for informed consent?
A. Explaining the risks and benefits of the surgery to the client
B. Witnessing the client’s signature on the consent form
C. Ensuring the client understands the alternative treatments available
D. Obtaining the signature from the next of kin before the client signs
Correct Answer: B
Rationale: The role of the nurse in the consent process is primarily to witness that the
signature is authentic and given voluntarily. It is the surgeon’s responsibility to explain the
procedure, risks, and benefits to the patient. If the nurse discovers the patient does not
understand the procedure, the surgeon must be notified to provide further clarification.
, 4. A nurse is assessing a client’s surgical incision on the second postoperative day and notes
thick, yellow-green drainage. How should the nurse document this finding?
A. Serous drainage
B. Sanguineous drainage
C. Purulent drainage
D. Serosanguineous drainage
Correct Answer: C
Rationale: Purulent drainage is characterized by thick, opaque fluid that may be yellow,
green, or tan, often indicating an infection. Sanguineous drainage is bright red blood, while
serous is clear and watery. Recognizing these differences is vital for the nurse to assess the
healing process and identify complications early.
5. Which nursing intervention is a priority for a client diagnosed with respiratory acidosis?
A. Maintaining a patent airway and improving ventilation
B. Administering sodium bicarbonate intravenously
C. Encouraging the client to breathe into a paper bag
D. Restricting fluid intake to prevent pulmonary congestion
Correct Answer: A
Rationale: Respiratory acidosis is caused by hypoventilation leading to the retention of
carbon dioxide. The primary goal of treatment is to improve gas exchange and clear the
