NUR160/NUR 160 Exam 1 V3 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a pressure injury and finds a shallow open ulcer with a red-pink wound
bed and no slough. Which stage should the nurse document?
A. Stage 1
B. Stage 3
C. Stage 2
D. Unstageable
Correct Answer: C
Rationale: A Stage 2 pressure injury involves partial-thickness loss of dermis presenting as
a shallow open ulcer with a red-pink wound bed, without slough. Stage 1 consists of non-
blanchable erythema of intact skin. Stage 3 involves full-thickness tissue loss with visible
subcutaneous fat but no bone, tendon, or muscle exposure.
2. Which clinical finding is most characteristic of a patient experiencing systemic fluid volume
excess?
A. Flattened neck veins when supine
B. Decreased blood pressure
,C. Poor skin turgor
D. Bounding peripheral pulses
Correct Answer: D
Rationale: Fluid volume excess (hypervolemia) leads to increased circulatory volume,
which results in bounding pulses and distended neck veins. Poor skin turgor and decreased
blood pressure are signs of fluid volume deficit or dehydration. The nurse must monitor for
pulmonary edema, often evidenced by crackles in the lungs.
3. A nurse is teaching a patient how to use an incentive spirometer. Which instruction is
correct?
A. Exhale forcefully into the device.
B. Use the device only twice a day.
C. Inhale deeply and slowly through the mouthpiece.
D. Keep the device below the level of the waist.
Correct Answer: C
Rationale: Incentive spirometry encourages deep, slow inhalation to maximize lung
expansion and prevent atelectasis. The patient should hold their breath for 3 to 5 seconds
at the peak of inhalation for maximum effect. This intervention is crucial for postoperative
patients to maintain airway clearance and oxygenation.
, 4. What is the priority nursing action when a patient’s surgical wound undergoes
evisceration?
A. Attempt to push the organs back into the abdominal cavity.
B. Apply a dry sterile dressing immediately.
C. Place the patient in a High-Fowler’s position.
D. Cover the protruding organs with sterile towels moistened with normal saline.
Correct Answer: D
Rationale: Evisceration is a medical emergency where internal organs protrude through
an open incision. Moistened sterile dressings protect the delicate tissues from drying out
and reduce the risk of infection. The nurse should also notify the surgeon immediately and
keep the patient in a low-Fowler’s position with knees flexed.
5. A patient with a potassium level of 2.8 mEq/L is at risk for which complication?
A. Muscle tetany
B. Cardiac dysrhythmias
C. Seizures
D. Hyperactive bowel sounds
Correct Answer: B
Rationale: Hypokalemia (low potassium) significantly affects cardiac electrical conduction,
potentially leading to lethal dysrhythmias. Normal potassium levels range from 3.5 to 5.0
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a pressure injury and finds a shallow open ulcer with a red-pink wound
bed and no slough. Which stage should the nurse document?
A. Stage 1
B. Stage 3
C. Stage 2
D. Unstageable
Correct Answer: C
Rationale: A Stage 2 pressure injury involves partial-thickness loss of dermis presenting as
a shallow open ulcer with a red-pink wound bed, without slough. Stage 1 consists of non-
blanchable erythema of intact skin. Stage 3 involves full-thickness tissue loss with visible
subcutaneous fat but no bone, tendon, or muscle exposure.
2. Which clinical finding is most characteristic of a patient experiencing systemic fluid volume
excess?
A. Flattened neck veins when supine
B. Decreased blood pressure
,C. Poor skin turgor
D. Bounding peripheral pulses
Correct Answer: D
Rationale: Fluid volume excess (hypervolemia) leads to increased circulatory volume,
which results in bounding pulses and distended neck veins. Poor skin turgor and decreased
blood pressure are signs of fluid volume deficit or dehydration. The nurse must monitor for
pulmonary edema, often evidenced by crackles in the lungs.
3. A nurse is teaching a patient how to use an incentive spirometer. Which instruction is
correct?
A. Exhale forcefully into the device.
B. Use the device only twice a day.
C. Inhale deeply and slowly through the mouthpiece.
D. Keep the device below the level of the waist.
Correct Answer: C
Rationale: Incentive spirometry encourages deep, slow inhalation to maximize lung
expansion and prevent atelectasis. The patient should hold their breath for 3 to 5 seconds
at the peak of inhalation for maximum effect. This intervention is crucial for postoperative
patients to maintain airway clearance and oxygenation.
, 4. What is the priority nursing action when a patient’s surgical wound undergoes
evisceration?
A. Attempt to push the organs back into the abdominal cavity.
B. Apply a dry sterile dressing immediately.
C. Place the patient in a High-Fowler’s position.
D. Cover the protruding organs with sterile towels moistened with normal saline.
Correct Answer: D
Rationale: Evisceration is a medical emergency where internal organs protrude through
an open incision. Moistened sterile dressings protect the delicate tissues from drying out
and reduce the risk of infection. The nurse should also notify the surgeon immediately and
keep the patient in a low-Fowler’s position with knees flexed.
5. A patient with a potassium level of 2.8 mEq/L is at risk for which complication?
A. Muscle tetany
B. Cardiac dysrhythmias
C. Seizures
D. Hyperactive bowel sounds
Correct Answer: B
Rationale: Hypokalemia (low potassium) significantly affects cardiac electrical conduction,
potentially leading to lethal dysrhythmias. Normal potassium levels range from 3.5 to 5.0
