,NU 171 Exam 2 | Comprehensive Questions & Verified
Answers | 2026 Edition | Galen College
1. Which of the following best describes the purpose of the Braden Scale?
A) To assess a patient's level of consciousness
B) To predict a patient's risk for developing a pressure injury
C) To evaluate a patient's nutritional status
D) To measure a patient's fall risk
Correct Answer: To predict a patient's risk for developing a pressure injury
Rationale: The Braden Scale evaluates sensory perception, moisture, activity, mobility, nutrition, and
friction/shear. Lower scores indicate higher pressure injury risk. It is not used for consciousness,
nutrition alone, or fall risk.
2. The nurse is preparing to administer an intramuscular injection of 2 mL of an irritating medication.
Which site is most appropriate?
A) Deltoid
B) Vastus lateralis
C) Ventrogluteal
D) Dorsogluteal
Correct Answer: Ventrogluteal
Rationale: The ventrogluteal site is deep, well-developed, and free of major nerves and blood vessels. It
can accommodate larger volumes (up to 3 mL) and is safer than the dorsogluteal site due to lower risk of
sciatic nerve injury.
3. When caring for a patient with a chest tube, the nurse notes continuous bubbling in the water-seal
chamber. What should the nurse do first?
A) Clamp the chest tube immediately
,B) Document the finding as normal
C) Check the tubing connections and insertion site for an air leak
D) Add more sterile water to the chamber
Correct Answer: Check the tubing connections and insertion site for an air leak
Rationale: Continuous bubbling indicates an air leak in the drainage system. The nurse must locate and
correct the leak. Clamping is not done without an order, and adding water does not fix the leak.
Intermittent bubbling with exhalation is expected initially.
4. The nurse is teaching a patient with heart failure about fluid restriction. The patient should
understand that fluid intake includes
A) only water and juice
B) all liquids at room temperature plus foods that become liquid at room temperature
C) only beverages consumed with meals
D) only fluids given intravenously
Correct Answer: All liquids at room temperature plus foods that become liquid at room temperature
Rationale: Fluid restriction includes all beverages, soups, gelatin, ice cream, and other items that are
liquid at room temperature. This comprehensive counting helps prevent fluid overload.
5. Which laboratory result is most indicative of renal function in a patient receiving gentamicin?
A) Serum glucose
B) Serum creatinine and blood urea nitrogen
C) Alanine aminotransferase
D) Complete blood count
Correct Answer: Serum creatinine and blood urea nitrogen
, Rationale: Gentamicin is nephrotoxic; rising creatinine and BUN indicate acute kidney injury. Peak and
trough levels are monitored to maintain therapeutic and safe dosing. Liver enzymes and CBC are not
primary indicators.
6. The nurse is assessing a patient who has been taking furosemide. Which finding suggests
hypokalemia?
A) Muscle weakness and cardiac arrhythmias
B) Hyperreflexia and tetany
C) Constipation and lethargy
D) Positive Chvostek sign
Correct Answer: Muscle weakness and cardiac arrhythmias
Rationale: Furosemide causes potassium loss. Hypokalemia manifests as muscle weakness, fatigue, and
potentially life-threatening cardiac dysrhythmias. Hyperreflexia and tetany indicate hypocalcemia.
Constipation and lethargy suggest hypercalcemia.
7. The nurse is to administer an IV push of furosemide. At what rate should this medication be
administered?
A) Rapidly over 1-2 seconds
B) Over 5 minutes
C) At a rate not exceeding 20 mg per minute
D) Mixed in a 100 mL bag and infused over 30 minutes
Correct Answer: At a rate not exceeding 20 mg per minute
Rationale: IV furosemide must be administered slowly to avoid ototoxicity and rapid fluid shifts. The
maximum recommended rate is 20 mg/min. Rapid push can cause irreversible hearing loss.
8. A patient is receiving a continuous infusion of heparin. The activated partial thromboplastin time
(aPTT) is 95 seconds, and the control is 30 seconds. The nurse should
A) continue the infusion at the current rate
Answers | 2026 Edition | Galen College
1. Which of the following best describes the purpose of the Braden Scale?
A) To assess a patient's level of consciousness
B) To predict a patient's risk for developing a pressure injury
C) To evaluate a patient's nutritional status
D) To measure a patient's fall risk
Correct Answer: To predict a patient's risk for developing a pressure injury
Rationale: The Braden Scale evaluates sensory perception, moisture, activity, mobility, nutrition, and
friction/shear. Lower scores indicate higher pressure injury risk. It is not used for consciousness,
nutrition alone, or fall risk.
2. The nurse is preparing to administer an intramuscular injection of 2 mL of an irritating medication.
Which site is most appropriate?
A) Deltoid
B) Vastus lateralis
C) Ventrogluteal
D) Dorsogluteal
Correct Answer: Ventrogluteal
Rationale: The ventrogluteal site is deep, well-developed, and free of major nerves and blood vessels. It
can accommodate larger volumes (up to 3 mL) and is safer than the dorsogluteal site due to lower risk of
sciatic nerve injury.
3. When caring for a patient with a chest tube, the nurse notes continuous bubbling in the water-seal
chamber. What should the nurse do first?
A) Clamp the chest tube immediately
,B) Document the finding as normal
C) Check the tubing connections and insertion site for an air leak
D) Add more sterile water to the chamber
Correct Answer: Check the tubing connections and insertion site for an air leak
Rationale: Continuous bubbling indicates an air leak in the drainage system. The nurse must locate and
correct the leak. Clamping is not done without an order, and adding water does not fix the leak.
Intermittent bubbling with exhalation is expected initially.
4. The nurse is teaching a patient with heart failure about fluid restriction. The patient should
understand that fluid intake includes
A) only water and juice
B) all liquids at room temperature plus foods that become liquid at room temperature
C) only beverages consumed with meals
D) only fluids given intravenously
Correct Answer: All liquids at room temperature plus foods that become liquid at room temperature
Rationale: Fluid restriction includes all beverages, soups, gelatin, ice cream, and other items that are
liquid at room temperature. This comprehensive counting helps prevent fluid overload.
5. Which laboratory result is most indicative of renal function in a patient receiving gentamicin?
A) Serum glucose
B) Serum creatinine and blood urea nitrogen
C) Alanine aminotransferase
D) Complete blood count
Correct Answer: Serum creatinine and blood urea nitrogen
, Rationale: Gentamicin is nephrotoxic; rising creatinine and BUN indicate acute kidney injury. Peak and
trough levels are monitored to maintain therapeutic and safe dosing. Liver enzymes and CBC are not
primary indicators.
6. The nurse is assessing a patient who has been taking furosemide. Which finding suggests
hypokalemia?
A) Muscle weakness and cardiac arrhythmias
B) Hyperreflexia and tetany
C) Constipation and lethargy
D) Positive Chvostek sign
Correct Answer: Muscle weakness and cardiac arrhythmias
Rationale: Furosemide causes potassium loss. Hypokalemia manifests as muscle weakness, fatigue, and
potentially life-threatening cardiac dysrhythmias. Hyperreflexia and tetany indicate hypocalcemia.
Constipation and lethargy suggest hypercalcemia.
7. The nurse is to administer an IV push of furosemide. At what rate should this medication be
administered?
A) Rapidly over 1-2 seconds
B) Over 5 minutes
C) At a rate not exceeding 20 mg per minute
D) Mixed in a 100 mL bag and infused over 30 minutes
Correct Answer: At a rate not exceeding 20 mg per minute
Rationale: IV furosemide must be administered slowly to avoid ototoxicity and rapid fluid shifts. The
maximum recommended rate is 20 mg/min. Rapid push can cause irreversible hearing loss.
8. A patient is receiving a continuous infusion of heparin. The activated partial thromboplastin time
(aPTT) is 95 seconds, and the control is 30 seconds. The nurse should
A) continue the infusion at the current rate
