NUR160/NUR 160 Exam 2 V2 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which of the
following priority nursing actions should be implemented?
A. Check the client for pedal edema
B. Encourage the intake of orange juice
C. Place the client on a cardiac monitor
D. Administer a dose of IV furosemide
Correct Answer: C
Rationale: A potassium level of 6.2 mEq/L indicates hyperkalemia, which significantly
increases the risk for lethal cardiac dysrhythmias. Placing the client on a cardiac monitor is
the priority to detect life-threatening changes like peaked T-waves or widened QRS
complexes. Other interventions like medications should only follow the stabilization and
monitoring of the heart’s electrical activity.
2. Which clinical manifestation would the nurse expect to find in a client experiencing fluid
volume deficit?
A. Increased heart rate
,B. Distended neck veins
C. Bounding peripheral pulses
D. Decreased urine specific gravity
Correct Answer: A
Rationale: Tachycardia is a compensatory mechanism used by the body to maintain
cardiac output when blood volume is low. Fluid volume deficit typically presents with a
weak, thready pulse rather than a bounding one. The kidneys will also attempt to conserve
water, leading to a high urine specific gravity, not a low one.
3. An LPN is preparing to witness a client signing an informed consent for surgery. What is the
primary role of the nurse in this process?
A. To explain the risks and benefits of the procedure
B. To verify that the client is signing voluntarily and is competent
C. To ensure the client understands the alternative treatments
D. To obtain the signature if the surgeon is busy
Correct Answer: B
Rationale: The nurse acts as a witness to the signature, confirming that the client is who
they say they are and is signing without coercion. It is the surgeon’s legal responsibility to
explain the risks, benefits, and alternatives of the procedure. If the nurse suspects the client
, does not understand the surgery, the surgeon must be called back to provide further
clarification.
4. A client is 12 hours postoperative following abdominal surgery. Which nursing intervention
is most effective in preventing deep vein thrombosis (DVT)?
A. Massaging the calves every 4 hours
B. Encouraging early and frequent ambulation
C. Placing pillows under the client’s knees
D. Limiting fluid intake to prevent edema
Correct Answer: B
Rationale: Ambulation promotes venous return by using the skeletal muscle pump, which
prevents blood stasis in the lower extremities. Massaging the calves is strictly
contraindicated because it could dislodge an existing clot. Placing pillows under the knees
can actually compress the popliteal vessels and increase the risk of thrombus formation.
5. While assessing a client’s IV site, the nurse notes coolness, swelling, and the client reports
pain. These findings are characteristic of which complication?
A. Infiltration
B. Phlebitis
C. Thrombophlebitis
D. Extravasation of a vesicant
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which of the
following priority nursing actions should be implemented?
A. Check the client for pedal edema
B. Encourage the intake of orange juice
C. Place the client on a cardiac monitor
D. Administer a dose of IV furosemide
Correct Answer: C
Rationale: A potassium level of 6.2 mEq/L indicates hyperkalemia, which significantly
increases the risk for lethal cardiac dysrhythmias. Placing the client on a cardiac monitor is
the priority to detect life-threatening changes like peaked T-waves or widened QRS
complexes. Other interventions like medications should only follow the stabilization and
monitoring of the heart’s electrical activity.
2. Which clinical manifestation would the nurse expect to find in a client experiencing fluid
volume deficit?
A. Increased heart rate
,B. Distended neck veins
C. Bounding peripheral pulses
D. Decreased urine specific gravity
Correct Answer: A
Rationale: Tachycardia is a compensatory mechanism used by the body to maintain
cardiac output when blood volume is low. Fluid volume deficit typically presents with a
weak, thready pulse rather than a bounding one. The kidneys will also attempt to conserve
water, leading to a high urine specific gravity, not a low one.
3. An LPN is preparing to witness a client signing an informed consent for surgery. What is the
primary role of the nurse in this process?
A. To explain the risks and benefits of the procedure
B. To verify that the client is signing voluntarily and is competent
C. To ensure the client understands the alternative treatments
D. To obtain the signature if the surgeon is busy
Correct Answer: B
Rationale: The nurse acts as a witness to the signature, confirming that the client is who
they say they are and is signing without coercion. It is the surgeon’s legal responsibility to
explain the risks, benefits, and alternatives of the procedure. If the nurse suspects the client
, does not understand the surgery, the surgeon must be called back to provide further
clarification.
4. A client is 12 hours postoperative following abdominal surgery. Which nursing intervention
is most effective in preventing deep vein thrombosis (DVT)?
A. Massaging the calves every 4 hours
B. Encouraging early and frequent ambulation
C. Placing pillows under the client’s knees
D. Limiting fluid intake to prevent edema
Correct Answer: B
Rationale: Ambulation promotes venous return by using the skeletal muscle pump, which
prevents blood stasis in the lower extremities. Massaging the calves is strictly
contraindicated because it could dislodge an existing clot. Placing pillows under the knees
can actually compress the popliteal vessels and increase the risk of thrombus formation.
5. While assessing a client’s IV site, the nurse notes coolness, swelling, and the client reports
pain. These findings are characteristic of which complication?
A. Infiltration
B. Phlebitis
C. Thrombophlebitis
D. Extravasation of a vesicant
