NSG 3130 Exam 2 V2 | NSG 3130
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 2) | Galen
College of Nursing
1. A nurse is assessing a client’s wound and notes a thick, yellow discharge. Which term
should the nurse use to document this finding in the medical record?
A. Serosanguineous drainage
B. Serous drainage
C. Purulent drainage
D. Sanguineous drainage
Answer: C
Rationale: Purulent drainage is thick and indicates infection, often appearing yellow,
green, or brown. The nurse must document this accurately as it reflects the inflammatory
response and possible bacterial presence. This type of drainage is distinct from serous or
sanguineous fluids which are usually clear or bloody.
2. When evaluating a patient using the Braden Scale, the nurse identifies a score of 12. What
is the clinical significance of this finding?
A. The patient is at low risk for pressure injuries.
,B. The patient is at moderate risk for pressure injuries.
C. The patient has no risk for pressure injuries.
D. The patient is at high risk for pressure injuries.
Answer: D
Rationale: A Braden Scale score of 12 indicates that the patient is at a high risk for
developing pressure injuries. Lower scores on this scale signify a higher risk level,
necessitating immediate preventative interventions. The scale assesses factors like sensory
perception, moisture, activity, mobility, nutrition, and friction.
3. Which electrolyte imbalance is most commonly associated with a positive Chvostek’s sign?
A. Hyperkalemia
B. Hypermagnesemia
C. Hyponatremia
D. Hypocalcemia
Answer: D
Rationale: Hypocalcemia increases neuromuscular irritability, which can be assessed by
tapping the facial nerve to elicit a twitch, known as Chvostek’s sign. This physical
manifestation is a critical indicator for the nurse to monitor the patient’s serum calcium
levels. Prompt recognition allows for the prevention of more severe complications like
tetany or seizures.
, 4. A patient presents with a serum potassium level of 6.2 mEq/L. Which nursing intervention
is the highest priority?
A. Administer a potassium-sparing diuretic.
B. Encourage the intake of potassium-rich foods.
C. Obtain an EKG to monitor for cardiac arrhythmias.
D. Assess the patient’s deep tendon reflexes.
Answer: C
Rationale: Hyperkalemia, defined here as 6.2 mEq/L, poses a significant risk for lethal
cardiac dysrhythmias. Monitoring the heart’s electrical activity via an EKG is the most
immediate safety priority for this patient. The nurse must recognize that elevated
potassium levels interfere with cardiac conduction and require rapid intervention.
5. A nurse is caring for a postoperative client. Which assessment finding is an early sign of
hypoxia?
A. Cyanosis of the nail beds
B. Bradycardia
C. Bradypnea
D. Restlessness and apprehension
Answer: D
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 2) | Galen
College of Nursing
1. A nurse is assessing a client’s wound and notes a thick, yellow discharge. Which term
should the nurse use to document this finding in the medical record?
A. Serosanguineous drainage
B. Serous drainage
C. Purulent drainage
D. Sanguineous drainage
Answer: C
Rationale: Purulent drainage is thick and indicates infection, often appearing yellow,
green, or brown. The nurse must document this accurately as it reflects the inflammatory
response and possible bacterial presence. This type of drainage is distinct from serous or
sanguineous fluids which are usually clear or bloody.
2. When evaluating a patient using the Braden Scale, the nurse identifies a score of 12. What
is the clinical significance of this finding?
A. The patient is at low risk for pressure injuries.
,B. The patient is at moderate risk for pressure injuries.
C. The patient has no risk for pressure injuries.
D. The patient is at high risk for pressure injuries.
Answer: D
Rationale: A Braden Scale score of 12 indicates that the patient is at a high risk for
developing pressure injuries. Lower scores on this scale signify a higher risk level,
necessitating immediate preventative interventions. The scale assesses factors like sensory
perception, moisture, activity, mobility, nutrition, and friction.
3. Which electrolyte imbalance is most commonly associated with a positive Chvostek’s sign?
A. Hyperkalemia
B. Hypermagnesemia
C. Hyponatremia
D. Hypocalcemia
Answer: D
Rationale: Hypocalcemia increases neuromuscular irritability, which can be assessed by
tapping the facial nerve to elicit a twitch, known as Chvostek’s sign. This physical
manifestation is a critical indicator for the nurse to monitor the patient’s serum calcium
levels. Prompt recognition allows for the prevention of more severe complications like
tetany or seizures.
, 4. A patient presents with a serum potassium level of 6.2 mEq/L. Which nursing intervention
is the highest priority?
A. Administer a potassium-sparing diuretic.
B. Encourage the intake of potassium-rich foods.
C. Obtain an EKG to monitor for cardiac arrhythmias.
D. Assess the patient’s deep tendon reflexes.
Answer: C
Rationale: Hyperkalemia, defined here as 6.2 mEq/L, poses a significant risk for lethal
cardiac dysrhythmias. Monitoring the heart’s electrical activity via an EKG is the most
immediate safety priority for this patient. The nurse must recognize that elevated
potassium levels interfere with cardiac conduction and require rapid intervention.
5. A nurse is caring for a postoperative client. Which assessment finding is an early sign of
hypoxia?
A. Cyanosis of the nail beds
B. Bradycardia
C. Bradypnea
D. Restlessness and apprehension
Answer: D
