NSG 3130 FUNDAMENTAL CONCEPTS &
SKILLS FOR NURSING PRACTICE II -
EXAM 3
1. A patient with chronic kidney disease presents with a potassium level of 6.2 mEq/L. Which
clinical finding is a priority for the nurse to monitor?
A. Increased bowel sounds
B. Polyuria and thirst
C. Hyperactive deep tendon reflexes
D. Tall, peaked T waves on EKG
Answer: D
Conceptual Explanation: Hyperkalemia (potassium > 5.0 mEq/L) can cause life-
threatening cardiac dysrhythmias, typically manifested as tall, peaked T waves or widened
QRS complexes on an EKG.
2. When assessing a patient with suspected metabolic acidosis, which respiratory pattern
would the nurse expect to observe?
A. Cheyne-Stokes respirations
,B. Bradypnea
C. Kussmaul respirations
D. Hypoventilation
Answer: C
Conceptual Explanation: Kussmaul respirations are deep, rapid breaths that occur as a
compensatory mechanism in metabolic acidosis to blow off excess carbon dioxide and
increase pH.
3. A nurse is caring for a patient who has a Stage III pressure injury. How should the nurse
document the appearance of this wound?
A. Non-blanchable erythema of intact skin
B. Partial-thickness loss of dermis presenting as a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone, tendon, or muscle
Answer: C
Conceptual Explanation: Stage III pressure injuries involve full-thickness tissue loss
where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.
4. Which action is most appropriate when a nurse discovers a surgical wound evisceration?
A. Apply a dry sterile dressing and call the surgeon
B. Gently push the organs back into the abdominal cavity
, C. Place the patient in a High-Fowler’s position
D. Cover the protruding organs with sterile towels soaked in normal saline
Answer: D
Conceptual Explanation: Evisceration is a medical emergency. The nurse should cover the
organs with sterile, saline-soaked dressings to keep them moist and prevent infection while
notifying the surgical team.
5. A nurse is preparing to administer an intramuscular injection using the Z-track technique.
What is the primary purpose of this method?
A. To ensure the medication is absorbed more rapidly
B. To prevent the medication from leaking into the subcutaneous tissue
C. To reduce the risk of hitting a bone
D. To decrease the amount of pain felt by the patient
Answer: B
Conceptual Explanation: The Z-track method seals the medication in the muscle tissue
and prevents it from tracking back into the subcutaneous space, which reduces irritation.
6. A patient is receiving total parenteral nutrition (TPN). The nurse should monitor for which
frequent metabolic complication?
A. Hypoglycemia
B. Hypernatremia
SKILLS FOR NURSING PRACTICE II -
EXAM 3
1. A patient with chronic kidney disease presents with a potassium level of 6.2 mEq/L. Which
clinical finding is a priority for the nurse to monitor?
A. Increased bowel sounds
B. Polyuria and thirst
C. Hyperactive deep tendon reflexes
D. Tall, peaked T waves on EKG
Answer: D
Conceptual Explanation: Hyperkalemia (potassium > 5.0 mEq/L) can cause life-
threatening cardiac dysrhythmias, typically manifested as tall, peaked T waves or widened
QRS complexes on an EKG.
2. When assessing a patient with suspected metabolic acidosis, which respiratory pattern
would the nurse expect to observe?
A. Cheyne-Stokes respirations
,B. Bradypnea
C. Kussmaul respirations
D. Hypoventilation
Answer: C
Conceptual Explanation: Kussmaul respirations are deep, rapid breaths that occur as a
compensatory mechanism in metabolic acidosis to blow off excess carbon dioxide and
increase pH.
3. A nurse is caring for a patient who has a Stage III pressure injury. How should the nurse
document the appearance of this wound?
A. Non-blanchable erythema of intact skin
B. Partial-thickness loss of dermis presenting as a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone, tendon, or muscle
Answer: C
Conceptual Explanation: Stage III pressure injuries involve full-thickness tissue loss
where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.
4. Which action is most appropriate when a nurse discovers a surgical wound evisceration?
A. Apply a dry sterile dressing and call the surgeon
B. Gently push the organs back into the abdominal cavity
, C. Place the patient in a High-Fowler’s position
D. Cover the protruding organs with sterile towels soaked in normal saline
Answer: D
Conceptual Explanation: Evisceration is a medical emergency. The nurse should cover the
organs with sterile, saline-soaked dressings to keep them moist and prevent infection while
notifying the surgical team.
5. A nurse is preparing to administer an intramuscular injection using the Z-track technique.
What is the primary purpose of this method?
A. To ensure the medication is absorbed more rapidly
B. To prevent the medication from leaking into the subcutaneous tissue
C. To reduce the risk of hitting a bone
D. To decrease the amount of pain felt by the patient
Answer: B
Conceptual Explanation: The Z-track method seals the medication in the muscle tissue
and prevents it from tracking back into the subcutaneous space, which reduces irritation.
6. A patient is receiving total parenteral nutrition (TPN). The nurse should monitor for which
frequent metabolic complication?
A. Hypoglycemia
B. Hypernatremia
