& Wound Care – Verified Q&A
This focused study guide is tailored specifically for Hondros College of Nursing students
preparing for the first exam in NUR 160: Fundamental Concepts of Practical Nursing
II. It provides a comprehensive review of the nursing process (ADPIE), focusing on the
critical assessment and planning phases required for clinical success. The material
includes verified practice questions and rationales for high-stakes topics like the 6 rights
of medication administration, sterile technique, and pressure injury staging. Updated for
the 2025/2026 curriculum, this guide helps bridge the gap between textbook theory and
the practical application needed to pass your first Fundamentals II assessment.
A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which of the
following should the nurse expect to see on the ECG?
A. Peaked T-waves
B. Widened QRS complex
C. Prominent U-waves
D. Shortened PR interval
Answer: C. Prominent U-waves
Rationale: Hypokalemia (low potassium) causes flattened T-waves and the
appearance of U-waves. Peaked T-waves are a sign of hyperkalemia.
A client has a sodium level of 150 mEq/L. Which of the following is the priority
nursing intervention?
A. Administer a 3% Sodium Chloride IV bolus.
B. Encourage increased oral water intake.
C. Restrict all fluid intake.
D. Administer a potassium-sparing diuretic.
Answer: B. Encourage increased oral water intake.
Rationale: The client has hypernatremia (high sodium/dehydration). The goal is
to dilute the sodium by increasing free water intake.
,What is the normal range for Magnesium?
A. 3.5 – 5.0 mEq/L
B. 1.3 – 2.1 mEq/L
C. 9.0 – 10.5 mg/dL
D. 135 – 145 mEq/L
Answer: B. 1.3 – 2.1 mEq/L
Rationale: Option A is potassium, C is calcium, and D is sodium.
A nurse is assessing a client for Trousseau’s sign. Which of the following actions
should the nurse take?
A. Tap the client’s facial nerve in front of the ear.
B. Inflate a blood pressure cuff on the client’s upper arm.
C. Ask the client to hyperventilate for 30 seconds.
D. Check the client’s deep tendon reflexes with a reflex hammer.
Answer: B. Inflate a blood pressure cuff on the client’s upper arm.
Rationale: Trousseau’s sign is a carpal spasm induced by inflating a BP cuff
above systolic pressure, indicating hypocalcemia. Tapping the face is Chvostek’s
sign.
A client's ABG results are: pH 7.31, PaCO2 52, HCO3 25. What is the
interpretation?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Answer: C. Respiratory acidosis
Rationale: The pH is low (acidic), and the CO2 is high (acidic). According to
R.O.M.E., when pH and CO2 move in opposite directions, it is respiratory.
Which IV solution is hypotonic and used to treat cellular dehydration?
A. 0.9% Normal Saline
B. Lactated Ringer’s
C. 0.45% Sodium Chloride (½ NS)
D. D5NS
Answer: C. 0.45% Sodium Chloride (½ NS)
Rationale: Hypotonic solutions have lower osmolality than blood, causing fluid to
move into the cells.
A nurse notes an IV site is red, warm to the touch, and has a red streak climbing the
arm. What is this?
, A. Infiltration
B. Extravasation
C. Phlebitis
D. Hematoma
Answer: C. Phlebitis
Rationale: Phlebitis is inflammation of the vein characterized by warmth and
redness. Infiltration would be cool and pale.
Which electrolyte imbalance is most likely to cause "positive" Chvostek’s and
Trousseau’s signs?
A. Hypermagnesemia
B. Hypocalcemia
C. Hypernatremia
D. Hypokalemia
Answer: B. Hypocalcemia
Rationale: Low calcium levels cause increased neuromuscular excitability,
leading to these specific tetany signs.
A client is scheduled for surgery. The nurse is witnessing the signature on the
informed consent. What is the nurse's role?
A. To explain the risks and benefits of the surgery.
B. To ensure the client understands the procedure.
C. To verify that the client signed the form voluntarily.
D. To tell the client about alternative treatment options.
Answer: C. To verify that the client signed the form voluntarily.
Rationale: The nurse acts only as a witness to the signature. The surgeon is
responsible for the actual "informed" part of the consent.
A client is 2 hours post-op and reports feeling thirsty and dizzy. The heart rate is
115/min and BP is 90/60. What is the nurse's priority action?
A. Give the client a glass of water.
B. Lower the head of the bed and notify the surgeon.
C. Encourage the use of the incentive spirometer.
D. Document the findings as normal post-op recovery.
Answer: B. Lower the head of the bed and notify the surgeon.
Rationale: These are signs of hypovolemic shock (hemorrhage). Lowering the
head of the bed helps with perfusion to the brain.
Which acid-base imbalance is caused by excessive diarrhea?
A. Respiratory acidosis
, B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Answer: B. Metabolic acidosis
Rationale: Diarrhea results in the loss of bicarbonate (base) from the lower GI
tract, leaving the body in an acidic state.
A nurse is assessing a client for fluid volume excess. Which of the following is an
expected finding?
A. Flat neck veins when supine
B. Sunken eyeballs
C. Distended jugular veins (JVD)
D. Poor skin turgor
Answer: C. Distended jugular veins (JVD)
Rationale: Fluid overload increases venous pressure, causing the neck veins to
bulge.
What is the primary extracellular cation?
A. Potassium
B. Calcium
C. Sodium
D. Phosphorus
Answer: C. Sodium
Rationale: Sodium is the most abundant cation outside the cell. Potassium is the
most abundant inside the cell.
A client is hyperventilating. Which ABG change is expected?
A. pH 7.49, PaCO2 28
B. pH 7.25, PaCO2 50
C. pH 7.35, HCO3 22
D. pH 7.40, PaCO2 40
Answer: A. pH 7.49, PaCO2 28
Rationale: Hyperventilation causes "blowing off" of CO2 (acid), leading to
respiratory alkalosis (high pH, low CO2).
A client has a calcium level of 12.0 mg/dL. Which symptom is expected?
A. Muscle spasms
B. Muscle weakness and constipation
C. Diarrhea
D. Positive Chvostek’s sign