NUR160/NUR 160 Exam 4 V2 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD) who is
experiencing shortness of breath. Which breathing technique should the nurse teach to help
the client promote carbon dioxide elimination?
A. Pursed-lip breathing
B. Deep abdominal breathing
C. Rapid, shallow breathing
D. Breath-holding at the end of inspiration
Correct Answer: A
Rationale: Pursed-lip breathing helps to maintain positive pressure in the airways and
prevents alveolar collapse during exhalation. This technique allows the client to exhale
more CO2 and reduces the amount of trapped air in the lungs. The nurse should instruct
the client to inhale through the nose and exhale slowly through puckered lips as if blowing
out a candle.
2. A client is prescribed Furosemide (Lasix) for the management of Heart Failure. Which
laboratory value should the nurse monitor most closely for potential complications?
A. Serum Potassium
,B. Serum Sodium
C. Serum Calcium
D. Serum Magnesium
Correct Answer: A
Rationale: Furosemide is a loop diuretic that causes the excretion of water, sodium, and
potassium through the kidneys. Hypokalemia is a common and dangerous side effect that
can lead to cardiac dysrhythmias and muscle weakness. The nurse must monitor the
client’s potassium levels regularly and encourage the intake of potassium-rich foods or
supplements as ordered.
3. The nurse is providing discharge instructions to a client newly diagnosed with Type 2
Diabetes Mellitus. Which statement by the client indicates a need for further teaching
regarding foot care?
A. I will wash my feet daily with lukewarm water and mild soap.
B. I will wear well-fitting leather shoes and change my socks daily.
C. I will apply moisturizing lotion between my toes to prevent cracking.
D. I will inspect the bottoms of my feet using a mirror every evening.
Correct Answer: C
Rationale: Moisture between the toes should be avoided because it creates an
environment conducive to fungal infections and skin breakdown. Clients with diabetes
,should apply lotion to the tops and bottoms of the feet but keep the interdigital spaces dry.
Proper foot care is essential to prevent complications such as ulcers and infections due to
peripheral neuropathy and poor circulation.
4. A client is 24 hours postoperative following abdominal surgery. Which nursing intervention
is most effective in preventing the development of atelectasis?
A. Assisting the client with incentive spirometry every hour while awake.
B. Maintaining the client in a supine position for the first 48 hours.
C. Limiting fluid intake to reduce pulmonary congestion.
D. Encouraging the client to avoid coughing to prevent wound dehiscence.
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing and helps to expand the
alveoli, which are prone to collapse after surgery due to shallow breathing and anesthesia.
This intervention promotes effective gas exchange and helps clear secretions from the
lungs. The nurse should also encourage the client to splint the incision site while coughing
to minimize pain and prevent complications.
5. The nurse is assessing a client with Right-Sided Heart Failure. Which clinical manifestation
should the nurse expect to find?
A. Crackles in the lungs upon auscultation
B. Productive cough with pink, frothy sputum
C. Dependent edema in the lower extremities
, D. Orthopnea and paroxysmal nocturnal dyspnea
Correct Answer: C
Rationale: Right-sided heart failure occurs when the right ventricle fails to pump blood
effectively into the pulmonary artery, leading to systemic venous congestion. This results in
clinical signs such as peripheral edema, jugular venous distention, and hepatomegaly.
Symptoms like crackles and frothy sputum are indicative of left-sided heart failure, where
blood backs up into the lungs.
6. A client with a history of hypertension is prescribed Lisinopril. Which side effect should the
nurse instruct the client to report immediately to the healthcare provider?
A. A persistent, dry nonproductive cough
B. Swelling of the face, lips, or tongue
C. Occasional dizziness when standing up quickly
D. A slight decrease in urinary output
Correct Answer: B
Rationale: Swelling of the face, lips, or tongue indicates angioedema, which is a life-
threatening adverse reaction to ACE inhibitors like Lisinopril. While a dry cough is a
common side effect, angioedema requires immediate medical intervention to prevent
airway obstruction. The nurse should educate the client on the signs of hypersensitivity
and the importance of seeking emergency care.
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD) who is
experiencing shortness of breath. Which breathing technique should the nurse teach to help
the client promote carbon dioxide elimination?
A. Pursed-lip breathing
B. Deep abdominal breathing
C. Rapid, shallow breathing
D. Breath-holding at the end of inspiration
Correct Answer: A
Rationale: Pursed-lip breathing helps to maintain positive pressure in the airways and
prevents alveolar collapse during exhalation. This technique allows the client to exhale
more CO2 and reduces the amount of trapped air in the lungs. The nurse should instruct
the client to inhale through the nose and exhale slowly through puckered lips as if blowing
out a candle.
2. A client is prescribed Furosemide (Lasix) for the management of Heart Failure. Which
laboratory value should the nurse monitor most closely for potential complications?
A. Serum Potassium
,B. Serum Sodium
C. Serum Calcium
D. Serum Magnesium
Correct Answer: A
Rationale: Furosemide is a loop diuretic that causes the excretion of water, sodium, and
potassium through the kidneys. Hypokalemia is a common and dangerous side effect that
can lead to cardiac dysrhythmias and muscle weakness. The nurse must monitor the
client’s potassium levels regularly and encourage the intake of potassium-rich foods or
supplements as ordered.
3. The nurse is providing discharge instructions to a client newly diagnosed with Type 2
Diabetes Mellitus. Which statement by the client indicates a need for further teaching
regarding foot care?
A. I will wash my feet daily with lukewarm water and mild soap.
B. I will wear well-fitting leather shoes and change my socks daily.
C. I will apply moisturizing lotion between my toes to prevent cracking.
D. I will inspect the bottoms of my feet using a mirror every evening.
Correct Answer: C
Rationale: Moisture between the toes should be avoided because it creates an
environment conducive to fungal infections and skin breakdown. Clients with diabetes
,should apply lotion to the tops and bottoms of the feet but keep the interdigital spaces dry.
Proper foot care is essential to prevent complications such as ulcers and infections due to
peripheral neuropathy and poor circulation.
4. A client is 24 hours postoperative following abdominal surgery. Which nursing intervention
is most effective in preventing the development of atelectasis?
A. Assisting the client with incentive spirometry every hour while awake.
B. Maintaining the client in a supine position for the first 48 hours.
C. Limiting fluid intake to reduce pulmonary congestion.
D. Encouraging the client to avoid coughing to prevent wound dehiscence.
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing and helps to expand the
alveoli, which are prone to collapse after surgery due to shallow breathing and anesthesia.
This intervention promotes effective gas exchange and helps clear secretions from the
lungs. The nurse should also encourage the client to splint the incision site while coughing
to minimize pain and prevent complications.
5. The nurse is assessing a client with Right-Sided Heart Failure. Which clinical manifestation
should the nurse expect to find?
A. Crackles in the lungs upon auscultation
B. Productive cough with pink, frothy sputum
C. Dependent edema in the lower extremities
, D. Orthopnea and paroxysmal nocturnal dyspnea
Correct Answer: C
Rationale: Right-sided heart failure occurs when the right ventricle fails to pump blood
effectively into the pulmonary artery, leading to systemic venous congestion. This results in
clinical signs such as peripheral edema, jugular venous distention, and hepatomegaly.
Symptoms like crackles and frothy sputum are indicative of left-sided heart failure, where
blood backs up into the lungs.
6. A client with a history of hypertension is prescribed Lisinopril. Which side effect should the
nurse instruct the client to report immediately to the healthcare provider?
A. A persistent, dry nonproductive cough
B. Swelling of the face, lips, or tongue
C. Occasional dizziness when standing up quickly
D. A slight decrease in urinary output
Correct Answer: B
Rationale: Swelling of the face, lips, or tongue indicates angioedema, which is a life-
threatening adverse reaction to ACE inhibitors like Lisinopril. While a dry cough is a
common side effect, angioedema requires immediate medical intervention to prevent
airway obstruction. The nurse should educate the client on the signs of hypersensitivity
and the importance of seeking emergency care.
