NUR160/NUR 160 Exam 3 V1 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. When suctioning a patient with a tracheostomy, what is the maximum amount of time the
nurse should apply suction?
A. 5 seconds
B. 20 to 30 seconds
C. 10 to 15 seconds
D. 1 minute
Correct Answer: C
Rationale: Suctioning should be limited to 10 to 15 seconds per pass to prevent significant
hypoxia in the patient. The nurse must allow the patient to rest for at least 30 to 60 seconds
between passes to re-oxygenate properly. Always hyper-oxygenate the patient before
starting the procedure to maintain safe oxygen saturation levels throughout the process.
2. A nurse observes that an intravenous (IV) site is cool to the touch, swollen, and pale. Which
complication should the nurse suspect?
A. Phlebitis
B. Infection
,C. Thrombophlebitis
D. Infiltration
Correct Answer: D
Rationale: Infiltration occurs when IV fluid leaks into the surrounding subcutaneous
tissue, causing coolness, pallor, and swelling at the site. The nurse should immediately stop
the infusion and remove the catheter to prevent further tissue damage. Elevating the
affected extremity and applying a warm or cold compress depending on the infusate can
help reduce discomfort and swelling.
3. Which clinical manifestation is most characteristic of a patient experiencing hypokalemia?
A. Nausea, vomiting, and diarrhea
B. Muscle weakness and cardiac dysrhythmias
C. Hyperactive deep tendon reflexes
D. Peaked T waves on an ECG
Correct Answer: B
Rationale: Hypokalemia, which is a low serum potassium level, primarily affects muscular
and cardiac function leading to weakness and potential arrhythmias. Patients may also
experience leg cramps and decreased bowel sounds due to reduced smooth muscle activity.
It is critical for the nurse to monitor the heart rate and rhythm closely while replacing
potassium as ordered.
,4. What is the nurse’s primary responsibility when a patient is signing an informed consent
for surgery?
A. Explaining the risks and benefits of the procedure
B. Witnessing the patient’s signature on the form
C. Describing alternative treatments available
D. Ensuring the surgeon has answered all technical questions
Correct Answer: B
Rationale: The nurse’s legal role in informed consent is to witness that the patient is
signing the form voluntarily and appears competent. It is the surgeon’s responsibility to
explain the procedure, risks, benefits, and alternatives to the patient. If the patient
expresses a lack of understanding, the nurse must notify the surgeon to return and provide
further clarification before the signature is obtained.
5. A patient with a new colostomy has a stoma that is beefy red and moist. Which action
should the nurse take?
A. Notify the surgeon immediately of a potential hemorrhage
B. Document the finding as normal for a new stoma
C. Apply a pressure dressing to the site
D. Irrigate the stoma with sterile normal saline
Correct Answer: B
, Rationale: A healthy, newly created stoma should appear beefy red and moist, indicating
adequate blood supply to the tissue. If the stoma appears pale, dusky, or blue, it suggests
impaired circulation and requires immediate medical attention. The nurse should
document this normal finding and continue to monitor for changes in color or output
during the healing phase.
6. Which stage of a pressure injury is characterized by a shallow, open ulcer with a red-pink
wound bed and no slough?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Correct Answer: C
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis and
present as a shallow open ulcer or a serum-filled blister. This stage does not involve visible
subcutaneous fat or deeper tissues like muscle or bone. Proper wound care at this stage
focuses on maintaining a moist healing environment and protecting the site from further
friction or pressure.
7. The nurse is checking the pH of gastric aspirate to verify NG tube placement. Which pH
value indicates the tube is likely in the stomach?
A. 7.35 to 7.45
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. When suctioning a patient with a tracheostomy, what is the maximum amount of time the
nurse should apply suction?
A. 5 seconds
B. 20 to 30 seconds
C. 10 to 15 seconds
D. 1 minute
Correct Answer: C
Rationale: Suctioning should be limited to 10 to 15 seconds per pass to prevent significant
hypoxia in the patient. The nurse must allow the patient to rest for at least 30 to 60 seconds
between passes to re-oxygenate properly. Always hyper-oxygenate the patient before
starting the procedure to maintain safe oxygen saturation levels throughout the process.
2. A nurse observes that an intravenous (IV) site is cool to the touch, swollen, and pale. Which
complication should the nurse suspect?
A. Phlebitis
B. Infection
,C. Thrombophlebitis
D. Infiltration
Correct Answer: D
Rationale: Infiltration occurs when IV fluid leaks into the surrounding subcutaneous
tissue, causing coolness, pallor, and swelling at the site. The nurse should immediately stop
the infusion and remove the catheter to prevent further tissue damage. Elevating the
affected extremity and applying a warm or cold compress depending on the infusate can
help reduce discomfort and swelling.
3. Which clinical manifestation is most characteristic of a patient experiencing hypokalemia?
A. Nausea, vomiting, and diarrhea
B. Muscle weakness and cardiac dysrhythmias
C. Hyperactive deep tendon reflexes
D. Peaked T waves on an ECG
Correct Answer: B
Rationale: Hypokalemia, which is a low serum potassium level, primarily affects muscular
and cardiac function leading to weakness and potential arrhythmias. Patients may also
experience leg cramps and decreased bowel sounds due to reduced smooth muscle activity.
It is critical for the nurse to monitor the heart rate and rhythm closely while replacing
potassium as ordered.
,4. What is the nurse’s primary responsibility when a patient is signing an informed consent
for surgery?
A. Explaining the risks and benefits of the procedure
B. Witnessing the patient’s signature on the form
C. Describing alternative treatments available
D. Ensuring the surgeon has answered all technical questions
Correct Answer: B
Rationale: The nurse’s legal role in informed consent is to witness that the patient is
signing the form voluntarily and appears competent. It is the surgeon’s responsibility to
explain the procedure, risks, benefits, and alternatives to the patient. If the patient
expresses a lack of understanding, the nurse must notify the surgeon to return and provide
further clarification before the signature is obtained.
5. A patient with a new colostomy has a stoma that is beefy red and moist. Which action
should the nurse take?
A. Notify the surgeon immediately of a potential hemorrhage
B. Document the finding as normal for a new stoma
C. Apply a pressure dressing to the site
D. Irrigate the stoma with sterile normal saline
Correct Answer: B
, Rationale: A healthy, newly created stoma should appear beefy red and moist, indicating
adequate blood supply to the tissue. If the stoma appears pale, dusky, or blue, it suggests
impaired circulation and requires immediate medical attention. The nurse should
document this normal finding and continue to monitor for changes in color or output
during the healing phase.
6. Which stage of a pressure injury is characterized by a shallow, open ulcer with a red-pink
wound bed and no slough?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Correct Answer: C
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis and
present as a shallow open ulcer or a serum-filled blister. This stage does not involve visible
subcutaneous fat or deeper tissues like muscle or bone. Proper wound care at this stage
focuses on maintaining a moist healing environment and protecting the site from further
friction or pressure.
7. The nurse is checking the pH of gastric aspirate to verify NG tube placement. Which pH
value indicates the tube is likely in the stomach?
A. 7.35 to 7.45
