NUR160/NUR 160 Exam 1 V1 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is performing a respiratory assessment on a patient with chronic obstructive
pulmonary disease (COPD). Which adventitious breath sound is most commonly associated
with air passing through narrowed bronchioles?
A. Crackles
B. Wheezes
C. Pleural friction rub
D. Stridor
Correct Answer: B
Rationale: Wheezes are high-pitched, musical sounds produced by narrowed airways,
often seen in COPD or asthma patients. Crackles usually indicate fluid in the smaller
airways or alveoli. The nurse must differentiate these sounds to provide the correct
interventions, such as administering bronchodilators.
2. The nurse is caring for an elderly patient with a suspected fluid volume deficit. Which
assessment finding is the most reliable indicator of dehydration in this population?
A. Poor skin turgor on the back of the hand
,B. Decreased blood pressure
C. Dry mucous membranes
D. Increased urine output
Correct Answer: C
Rationale: Dry mucous membranes are a more reliable indicator of dehydration in the
elderly because skin turgor naturally decreases with age. A drop in blood pressure can
occur, but it may also be related to medications or other cardiovascular issues. Monitoring
mucous membranes provides a clearer clinical picture of the patient’s hydration status.
3. A patient is prescribed a clear liquid diet post-surgery. Which of the following items can the
nurse safely include on the patient’s meal tray?
A. Vanilla pudding
B. Orange juice with pulp
C. Apple juice
D. Cream of mushroom soup
Correct Answer: C
Rationale: Apple juice is considered a clear liquid because it is transparent at room
temperature and leaves no residue. Items like pudding and creamed soups are part of a full
liquid diet, not a clear liquid diet. Ensuring the correct diet stage is vital to prevent post-
operative complications like nausea or vomiting.
, 4. While assessing a patient’s pain, the nurse asks the patient to describe the quality of the
pain. Which statement by the patient refers to the quality?
A. The pain started about two hours ago.
B. The pain is an 8 on a scale of 0 to 10.
C. The pain is a sharp, stabbing sensation.
D. The pain radiates down my left arm.
Correct Answer: C
Rationale: Describing pain as ‘sharp’ or ‘stabbing’ refers to the quality of the sensation.
Numerical ratings refer to intensity, while timing refers to onset and duration. Accurate
assessment of pain quality helps the healthcare provider determine the possible underlying
cause and appropriate treatment.
5. The nurse is preparing to administer an intramuscular injection to an adult. Which site is
preferred to minimize the risk of nerve or vascular injury?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
Correct Answer: B
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is performing a respiratory assessment on a patient with chronic obstructive
pulmonary disease (COPD). Which adventitious breath sound is most commonly associated
with air passing through narrowed bronchioles?
A. Crackles
B. Wheezes
C. Pleural friction rub
D. Stridor
Correct Answer: B
Rationale: Wheezes are high-pitched, musical sounds produced by narrowed airways,
often seen in COPD or asthma patients. Crackles usually indicate fluid in the smaller
airways or alveoli. The nurse must differentiate these sounds to provide the correct
interventions, such as administering bronchodilators.
2. The nurse is caring for an elderly patient with a suspected fluid volume deficit. Which
assessment finding is the most reliable indicator of dehydration in this population?
A. Poor skin turgor on the back of the hand
,B. Decreased blood pressure
C. Dry mucous membranes
D. Increased urine output
Correct Answer: C
Rationale: Dry mucous membranes are a more reliable indicator of dehydration in the
elderly because skin turgor naturally decreases with age. A drop in blood pressure can
occur, but it may also be related to medications or other cardiovascular issues. Monitoring
mucous membranes provides a clearer clinical picture of the patient’s hydration status.
3. A patient is prescribed a clear liquid diet post-surgery. Which of the following items can the
nurse safely include on the patient’s meal tray?
A. Vanilla pudding
B. Orange juice with pulp
C. Apple juice
D. Cream of mushroom soup
Correct Answer: C
Rationale: Apple juice is considered a clear liquid because it is transparent at room
temperature and leaves no residue. Items like pudding and creamed soups are part of a full
liquid diet, not a clear liquid diet. Ensuring the correct diet stage is vital to prevent post-
operative complications like nausea or vomiting.
, 4. While assessing a patient’s pain, the nurse asks the patient to describe the quality of the
pain. Which statement by the patient refers to the quality?
A. The pain started about two hours ago.
B. The pain is an 8 on a scale of 0 to 10.
C. The pain is a sharp, stabbing sensation.
D. The pain radiates down my left arm.
Correct Answer: C
Rationale: Describing pain as ‘sharp’ or ‘stabbing’ refers to the quality of the sensation.
Numerical ratings refer to intensity, while timing refers to onset and duration. Accurate
assessment of pain quality helps the healthcare provider determine the possible underlying
cause and appropriate treatment.
5. The nurse is preparing to administer an intramuscular injection to an adult. Which site is
preferred to minimize the risk of nerve or vascular injury?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
Correct Answer: B
