NUR160/NUR 160 Exam 2 V3 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing an IV site and notes that the skin is cool to the touch, pale, and
swollen. Which complication is the nurse most likely observing?
A. Phlebitis
B. Infiltration
C. Thrombosis
D. Infection
Correct Answer: B
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue. Common signs include coolness, pallor, and local edema at the
insertion site. The nurse should immediately stop the infusion and remove the IV catheter
as the primary intervention.
2. When a patient is diagnosed with hypokalemia, which of the following medications in the
patient’s record should concern the nurse the most?
A. Metformin
B. Lisinopril
,C. Digoxin
D. Albuterol
Correct Answer: C
Rationale: Low potassium levels significantly increase the risk of digoxin toxicity in
patients. The nurse must monitor for symptoms such as visual changes, nausea, and cardiac
arrhythmias. If the potassium level is below the reference range, the nurse should consult
the provider before administration.
3. A nurse is caring for a patient with a pressure ulcer that involves full-thickness skin loss
with visible subcutaneous fat, but no bone or muscle is exposed. How should this be staged?
A. Stage III
B. Stage II
C. Stage I
D. Stage IV
Correct Answer: A
Rationale: Stage III pressure ulcers involve full-thickness skin loss that extends into the
subcutaneous tissue layer. Although fat may be visible, the wound does not yet expose
underlying bone, tendon, or muscle. Proper documentation and wound care protocols are
essential for promoting secondary intention healing.
, 4. A patient requires a high concentration of oxygen and is currently using a mask with a
reservoir bag that must remain partially inflated during inspiration. Which device is being
used?
A. Simple face mask
B. Venturi mask
C. Non-rebreather mask
D. Nasal cannula
Correct Answer: C
Rationale: A non-rebreather mask is designed to deliver high concentrations of oxygen by
using a reservoir bag. It is critical that the bag remains at least one-third to one-half full
during inhalation to ensure the patient receives the correct dose. This device is typically
used for patients who are severely hypoxic or in respiratory distress.
5. Which electrolyte imbalance is characterized by a positive Chvostek’s sign and Trousseau’s
sign?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypomagnesemia
Correct Answer: C
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing an IV site and notes that the skin is cool to the touch, pale, and
swollen. Which complication is the nurse most likely observing?
A. Phlebitis
B. Infiltration
C. Thrombosis
D. Infection
Correct Answer: B
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue. Common signs include coolness, pallor, and local edema at the
insertion site. The nurse should immediately stop the infusion and remove the IV catheter
as the primary intervention.
2. When a patient is diagnosed with hypokalemia, which of the following medications in the
patient’s record should concern the nurse the most?
A. Metformin
B. Lisinopril
,C. Digoxin
D. Albuterol
Correct Answer: C
Rationale: Low potassium levels significantly increase the risk of digoxin toxicity in
patients. The nurse must monitor for symptoms such as visual changes, nausea, and cardiac
arrhythmias. If the potassium level is below the reference range, the nurse should consult
the provider before administration.
3. A nurse is caring for a patient with a pressure ulcer that involves full-thickness skin loss
with visible subcutaneous fat, but no bone or muscle is exposed. How should this be staged?
A. Stage III
B. Stage II
C. Stage I
D. Stage IV
Correct Answer: A
Rationale: Stage III pressure ulcers involve full-thickness skin loss that extends into the
subcutaneous tissue layer. Although fat may be visible, the wound does not yet expose
underlying bone, tendon, or muscle. Proper documentation and wound care protocols are
essential for promoting secondary intention healing.
, 4. A patient requires a high concentration of oxygen and is currently using a mask with a
reservoir bag that must remain partially inflated during inspiration. Which device is being
used?
A. Simple face mask
B. Venturi mask
C. Non-rebreather mask
D. Nasal cannula
Correct Answer: C
Rationale: A non-rebreather mask is designed to deliver high concentrations of oxygen by
using a reservoir bag. It is critical that the bag remains at least one-third to one-half full
during inhalation to ensure the patient receives the correct dose. This device is typically
used for patients who are severely hypoxic or in respiratory distress.
5. Which electrolyte imbalance is characterized by a positive Chvostek’s sign and Trousseau’s
sign?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypomagnesemia
Correct Answer: C
