NUR160/NUR 160 Exam 2 V1 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client who has a suspected fecal impaction. Which of the following
digital rectal examination findings should the nurse expect?
A. A hard, stony mass felt in the rectum
B. Soft, formed stool in the rectal vault
C. Bright red blood on the gloved finger
D. Presence of liquid stool only
Correct Answer: A
Rationale: Fecal impaction is characterized by the presence of a hard, immovable mass of
stool in the rectum that the client cannot pass. This condition often results from chronic
constipation or the use of certain medications like opioids. The nurse must perform a
digital exam carefully to avoid stimulating the vagus nerve.
2. When assessing a client with a stage 3 pressure injury, which tissue layer should the nurse
expect to be visible?
A. Subcutaneous fat
B. Muscle and bone
,C. Epidermis and dermis only
D. Non-blanchable erythema
Correct Answer: A
Rationale: A stage 3 pressure injury involves full-thickness skin loss that extends into the
subcutaneous tissue layer. Unlike stage 4, muscle, tendon, and bone are not exposed in a
stage 3 injury. It is critical for the nurse to document the presence of slough or eschar if
present, as these can obscure the depth of the wound.
3. A nurse is providing discharge teaching to a client with a new colostomy. Which statement
by the client indicates a need for further teaching?
A. “I should empty the pouch when it is one-third full.”
B. “I will decrease my fluid intake to make the stool thicker.”
C. “The stoma should look moist and reddish-pink.”
D. “I need to cut the wafer slightly larger than the stoma.”
Correct Answer: B
Rationale: Clients with a colostomy should maintain adequate fluid intake to prevent
constipation and promote healthy output. Restricting fluids can lead to dehydration and
hard stools, which are difficult to manage with an ostomy. The nurse should reinforce that
a balanced diet and hydration are essential for ostomy health.
, 4. Which of the following is an early sign of hypoxia that a nurse should monitor for in a post-
operative client?
A. Restlessness
B. Cyanosis
C. Bradycardia
D. Bradypnea
Correct Answer: A
Rationale: Restlessness and anxiety are among the earliest clinical indicators of hypoxia as
the brain responds to decreasing oxygen levels. Cyanosis and bradycardia are considered
late signs and indicate a more severe state of respiratory distress. Frequent monitoring of
mental status and vital signs is essential for early detection.
5. A nurse is preparing to administer a cleansing enema to a client. In which position should
the nurse place the client?
A. High-Fowler’s
B. Lithotomy
C. Left Sim’s
D. Prone
Correct Answer: C
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client who has a suspected fecal impaction. Which of the following
digital rectal examination findings should the nurse expect?
A. A hard, stony mass felt in the rectum
B. Soft, formed stool in the rectal vault
C. Bright red blood on the gloved finger
D. Presence of liquid stool only
Correct Answer: A
Rationale: Fecal impaction is characterized by the presence of a hard, immovable mass of
stool in the rectum that the client cannot pass. This condition often results from chronic
constipation or the use of certain medications like opioids. The nurse must perform a
digital exam carefully to avoid stimulating the vagus nerve.
2. When assessing a client with a stage 3 pressure injury, which tissue layer should the nurse
expect to be visible?
A. Subcutaneous fat
B. Muscle and bone
,C. Epidermis and dermis only
D. Non-blanchable erythema
Correct Answer: A
Rationale: A stage 3 pressure injury involves full-thickness skin loss that extends into the
subcutaneous tissue layer. Unlike stage 4, muscle, tendon, and bone are not exposed in a
stage 3 injury. It is critical for the nurse to document the presence of slough or eschar if
present, as these can obscure the depth of the wound.
3. A nurse is providing discharge teaching to a client with a new colostomy. Which statement
by the client indicates a need for further teaching?
A. “I should empty the pouch when it is one-third full.”
B. “I will decrease my fluid intake to make the stool thicker.”
C. “The stoma should look moist and reddish-pink.”
D. “I need to cut the wafer slightly larger than the stoma.”
Correct Answer: B
Rationale: Clients with a colostomy should maintain adequate fluid intake to prevent
constipation and promote healthy output. Restricting fluids can lead to dehydration and
hard stools, which are difficult to manage with an ostomy. The nurse should reinforce that
a balanced diet and hydration are essential for ostomy health.
, 4. Which of the following is an early sign of hypoxia that a nurse should monitor for in a post-
operative client?
A. Restlessness
B. Cyanosis
C. Bradycardia
D. Bradypnea
Correct Answer: A
Rationale: Restlessness and anxiety are among the earliest clinical indicators of hypoxia as
the brain responds to decreasing oxygen levels. Cyanosis and bradycardia are considered
late signs and indicate a more severe state of respiratory distress. Frequent monitoring of
mental status and vital signs is essential for early detection.
5. A nurse is preparing to administer a cleansing enema to a client. In which position should
the nurse place the client?
A. High-Fowler’s
B. Lithotomy
C. Left Sim’s
D. Prone
Correct Answer: C
