Exam: NUR160 / NUR 160 (Latest 2023/
2024) Fundamental Concepts of Practical
Nursing II Exam Review | Questions and
Verified Answers| Already Graded A|
Hondros College
The nurse knows the most accurate way to determine Water balance in the body is
which of the following? – ANSWER
Weighing The patient at the same time and same scale
The Nurse Understands the population at most risk for fluid and electrolyte
imbalance are which of the following? – ANSWER
Infants
geriatrics
The nurse assessing a patient that has exhibited positive Chovestick and Trousseau
signs. The nurse knows these are signs of which imbalance? – ANSWER
Hypocalcemia
Which is the correct process for measuring the length for nasogastric tube (NGT)
insertion? – ANSWER Tip of not to
earlobe to xiphoid process
The nurse knows the importance of making sure the nasogastric tube is properly
placed in the stomach of the patient. Which of the following is noted for being best
practice on verifying nasogastric tube placement? – ANSWER
Abdominal/ Thoracic chest x-ray
A patient is exhibiting the following signs and symptoms: dry mucus membranes,
poor skin turgor and tenting of skin. The nurse knows there are signs and
symptoms of which of the following? – ANSWER
Fluid volume deficit (FVD)
A patient is refusing to ambulate to the bedside commode. Which Statement by the
patient is related to their refusal to ambulate? – ANSWER
I saw my roommate fall last week when going to the bathroom”
A patient with emphysema is having difficulty breathing after ambulating to the
bathroom. Which medication will the patient take for immediate relief of the
breathing difficulty? – ANSWER
Albuterol (Proventil)
The LPN is caring for a patient with a nasogastric tube (NGT) following gastric
surgery. The patient has an order for metropolol (Lopressor) 25 mg extendedrelease capsule. Which is the LPN’s best intervention? – ANSWER
Call Physician to clarify order
The nurse understands Vitamin D is necessary for the absorption of which
electrolyte? – ANSWER Calcium
When will the nurse begin discharge instructions with a surgical patient? –
ANSWER During pre operative stage
The nurse is teaching oxygen safety to the nursing assistant on safe oxygen
administration and possible issues that should be reported to the nurse. Which
statement by the nursing assistant indicates a need for further information. –
ANSWER will keep an extra cylinder of
oxygen in the corner of the room by the heater”
Exam 1: NUR160 / NUR 160 (Latest 2023/
2024) Fundamental Concepts of Practical
Nursing II Exam Review | Questions and
Verified Answers| Already Graded A|
Hondros College
Who creates the National Patient Safety Goals? – ANSWER
The Joint Commission
What organization promotes workplace safety? – ANSWER
OSHA
What does OSHA stand for? – ANSWER Occupational Safety
and Health Administration
Who are at risk for falls? – ANSWER Older adults, post-op,
people with vertigo
What types of things place people at risk for falls? – ANSWER
History of falls, parkinson’s, visually impaired, medications, difficulty walking
What do we do that can increase someones risk of falls? – ANSWER
Not putting call light in reach, not raising bed rails, IV poles, TELEMETRY- HEART
MONITOR CAN INCREASE RISK OF FALLS, EXTRA TUBES, FOLEYS etc
What interventions can we do to help with fall risks? – ANSWER
Keep room clear of safety hazards, call light in reach, explain how to use it,
engage with patient, place patients at highest risk closest to nursing schedule so
they’re not rushing to the bathroom, constant checks, well-lit room.
What are the 6 rights of medication administration? – ANSWER
Right time, right person, right route, right documentation, right medication, right
dosage
What do we do if a patient refuses medications? – ANSWER
(assess) Ask them why they don’t want to take it then educate patient. IF they still
refuse document refusal and let the physician know.
What are the types of diagnostic errors? – ANSWER
Diagnostic, communication, treatment, preventative
What are the two different placements of errors? – ANSWER
Latent error: Flaw in the organization or a system error such as wrong medication
stocked in a certain section
Active error: an error lol
What can we do to prevent errors? – ANSWER
Communication, use rights of medications, use 3 checks on medication, being
more aware, educate patient
What is Just culture? – ANSWER Freedom to communicate
mistake or error without getting into trouble for purpose of education and
prevent errors, also called root of problem. All in order to prevent it from
happening again
2 types of advanced directives? – ANSWER Living will:
persons written out will during medical decisions and after death
Power of attorney: giving someone permission to make those medical decisions
for you
What are mandated reporters? – ANSWER Nurses are
required to report abuse if you believe someone is being abused or if they tell
Exam 3: NUR160 / NUR 160 (Latest 2023/
2024) Fundamental Concepts of Practical
Nursing II Exam Review | Questions and
Verified Answers| Already Graded A|
Hondros College
define arthritis – ANSWER inflammation of a joint
name the 4 types of arthritis – ANSWER
osteoarthritis, rheumatoid arthritis, osteoporosis, gout
what causes OA? – ANSWER long-term or
excessive wear and tear on joints
name the two forms of OA – ANSWER primary
and secondary
what is the cause of primary OA? – ANSWER
unknown origin
what is the cause of secondary OA? – ANSWER
trauma, infection, previous fractures, wear and tear from rep work, stress on
weight-bearing joints, RA, occupational stooping and bending
OA signs and symptoms – ANSWER pain,
stiffness, tenderness, swelling, loss of flexibility, bone spurs, grinding/crackling
noises
list OA diagnostics – ANSWER x-ray, MRI, bone
scans
list medical managements for OA – ANSWER
Tylenol, NSAIDs, Celebrex, ambulation, massage therapy, and relaxation
techniques, and surgical intervention
list OA nursing interventions – ANSWER alternate
positions w/ periods of rest, encourage maintenance of ADLs, weight reduction
plan, assess for GI bleeding, walking aids
foods to avoid for OA – ANSWER processed
foods, prepackaged meals, omega-6 fatty acids, sugar and sugar alternatives, red
meat, fried foods, refined carbs, cheese, high fat dairy, and alcohol
foods that help OA – ANSWER oily fish (omega-3
fatty acids), oils, dairy, leafy greens, broccoli, green tea, garlic, nuts
Exam 2: NUR160 / NUR 160 (Latest 2023/
2024) Fundamental Concepts of Practical
Nursing II Exam Review | Questions and
Verified Answers| Already Graded A|
Hondros College
What causes increased residual regarding NG tubes? – ANSWER
The inability to forcibly expire and remove air from the lungs
Actual procedure for NG tubes – ANSWER
Aspirate vicious lidocaine into syringe
Estimation of NG tubes length from the nostril to the ear to the sternum
NG tube lubrication with water based lubricant
Have patient flex neck back then toward
Auscultate stomach, get an X-ray to check placement
What to assess with FVE – ANSWER Asses
extremities for edema
Take vitals
Asses their pulse for a bounding pulse
Asses I&Os
What to do with a new onset of signs and symptoms – ANSWER
Consistently monitor their s/s
Make sure the symptoms don’t get worse
Pulse sites – ANSWER radial, temporal,
carotid, apical, brachial, femoral, popliteal, posterior tibial, dorsalis pedis
When discharge begins with normal/surgical admission – ANSWER
Right at admission
incentive spirometry – ANSWER
Postoperative breathing therapy that promotes deep breathing, use 10 times a
hours
Pulse of education – ANSWER Warm hands
No fake nails
No fingernail polish
Normal range between 95-100
Don’t do it in direct sunlight
When is it necessary to check blood glucose – ANSWER
Before and after meals
Actual procedure for blood glucose – ANSWER
Gather blood glucose meter, test strip, lancing device
Wash and dry hands
Turn on meter and prepare test strip
Choose spot on finger on side
Never use the same side in a row
Prick finger
Wipe first drop of blood with gauze then test blood
What can be delegated to a UAP – ANSWER
I&Os
Assisting with ADLs
Bathing
Toileting
Ambulating
Feeding
Exam 1: NUR160 / NUR 160 (Latest 2023/
2024) Fundamental Concepts of Practical
Nursing II Exam Review | Questions and
Verified Answers| Already Graded A|
Hondros College
The nurse is providing care within the total care context. What should the nurse
consider when using this care approach?
- The individualism of the client
- Principles applicable to the client at this moment
- Principles general to all clients of the same age and condition
- The persons self-identity – ANSWER Correct
Answer: 3
Rationale 1: In the individualized care context, the nurse becomes acquainted
with the client as an individual, referring to the total care principles and using
those principles that apply to this person at this time.
Rationale 2: In the individualized care context, the nurse becomes acquainted
with the client as an individual, referring to the total care principles and using
those principles that apply to this person at this time.
Rationale 3: In the total care context, the nurse considers all the principles and
areas that apply when taking care of any client of that age and condition.
Rationale 4: The persons self-identity is part of the individual health dimension of
any one client.
The nurse is practicing the concept of holism with a client. Which action is the
nurse most likely making?
- Considering how the loss of a client’s job will affect the regulation of the client’s
diabetes - Making sure to do complete teaching regarding pharmacological interventions
- Following physician treatments on schedule
- Prioritizing the needs of the client assigned according to Maslow’s hierarchy –
ANSWER Correct Answer: 1
Rationale 1: The concept of holism emphasizes that nurses must keep the whole
person in mind and strives to understand how one area of concern relates to the
whole person. In this situation, the stress from a job loss will affect the persons
chronic condition. The nurse must also consider the relationship of the individual
to the external environment and to others.
Rationale 2: This option is only focused on the physiology of the persons
condition.
Rationale 3: This option is only focused on the physiology of the persons
condition.
Rationale 4: This option is only focused on the physiology of the persons
condition.
Psychologic homeostasis is maintained by a variety of mechanisms. Which client
should the nurse identify as being the most likely candidate to obtain psychologic
homeostasis? - A child who is used to getting ready for school alone
- A teenager whose circle of friends includes single parents of the same age
- An elderly person who has just moved to a long-term care facility
- A young adult who is in a long-term relationship – ANSWER
Correct Answer: 4
Rationale 1: Psychologic homeostasis is acquired or learned through the
experience of living and interacting with others. Individuals can develop
psychologic homeostasis if they are in a stable physical environment where they
feel safe and secure. A child who is alone while getting ready for school may not
feel safe and secure.
Rationale 2: Individuals also need a stable psychologic environment from infancy
onward so that feelings of love and trust develop, a social environment that
includes adults who are healthy role models, and a life experience that provides
satisfaction. Having friends of the same age who are parents may eliminate
healthy adult role models for the teenager.
Rationale 3: Individuals also need a stable psychologic environment from infancy
onward so that feelings of love and trust develop, a social environment that
includes adults who are healthy role models, and a life experience that provides
satisfaction. Moving into a long-term care facility can be a huge adjustment for
some people, which may affect feelings of safety and security.
Rationale 4: Individuals also need a stable psychologic environment from infancy
onward so that feelings of love and trust develop, a social environment that
includes adults who are healthy role models, and a life experience that provides
satisfaction. A young adult who has a relationship that lasts is the one option that
would fit most of these mechanisms.
A client is having difficulty with feelings of self-loathing and disgust after being
attacked and raped. According to Maslow’s human needs theory, at which level
should the nurse recognize that the client is struggling?
- Physiological
- Safety and security
- Love and belonging
- Self-esteem – ANSWER Correct Answer: 4
Rationale 1: Physiological needs include air, food, water, rest, and sleep.
Rationale 2: Safety and security needs are those things, both psychological and
physiological, that help the person feel safe.
Rationale 3: Love and belonging needs include giving and receiving affection,
attaining a place in a group, and maintaining the feeling of belonging.
Rationale 4: Self-esteem and esteem from others includes feelings of
independence, competence, self-respect, recognition, respect, and appreciation.
Self-hatred and disgust is opposite of what one would expect in the self-esteem
level of Maslow’s model.
A client is hospitalized with numerous acute health problems. According to
Maslow’s basic needs model, which nursing diagnosis should the nurse identify as
being the highest priority for this client?
- Risk for Injury related to unsteady gait
- Altered Nutrition, Less Than Body Requirements related to inability to absorb
nutrients - Self-Care Deficit related to weakness and debilitation
- Powerlessness related to chronic disease state – ANSWER
Correct Answer: 2
Rationale 1: Risk for Injury would be the lower priority need.
Rationale 2: In needs theories, human needs are ranked on an ascending scale
according to how essential the needs are for survival. Physiologic needs are those
such as air, food, water, shelter, rest, sleep, activity, and temperature
maintenance, which are all crucial for survival. Nutritional deficits would fall into
this level and take priority over the others listed.
Rationale 3: Self-Care Deficit would fall in the fourth level self-esteem needs.
Rationale 4: Powerlessness is part of the need to develop one’s maximum
potential. It falls into the fifth and highest level of self-actualization.
The nurse is using Kalishs adaptation of Maslow’s hierarchy of needs when
planning client care. Which client should the nurse identify as exhibiting a level of
Kalishs adaptation? - Has a homosexual encounter for the first time
- Has a need to participate in school sports and be on the team
- Strives to become the CEO of a company
- Is sleep deprived because of musculoskeletal discomfort – ANSWER
Correct Answer: 1
Final Exam: NUR160 / NUR 160 (Latest
2023/ 2024) Fundamental Concepts of
Practical Nursing II Exam Review |
Questions and Verified Answers| Already
Graded A| Hondros College
Place the steps of the problem-solving approach in the appropriate order.
(Separate letters with a comma and space as follows: A, B, C, D, E.)
A. Predict the likelihood of each outcome occurring.
B. Choose the alternative with the best chance of success.
C. Consider all possible alternatives as the solution to the problem.
D. Identify the problem.
E. Examine possible outcomes of each alternative. – ANSWER
D, C, E, A, B.
A blind, elderly patient is admitted to the hospital for dehydration and weakness.
The nurse can make the admission process less stressful by: – ANSWER
Performing the initial assessment in a non-hurried manner.
A clinic nurse is documenting in a patient chart about the pain that brought the
patient to seek medical attention. The best description is: – ANSWER
“Peri-umbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours
after lunch. No relief from antacids.
A hospitalized patient tells the nurse that he intends to leave the hospital, against
medical advice. The nurse’s initial action(s) should be to: – ANSWER
Listen to patient, answer questions, and offer to have the supervisor or physician
speak with patient.
A major concern for an 86-year-old patient who has been NPO for 8 hours prior to
a diagnostic test would be: – ANSWER hydration
status
A male patient who suffered a spinal cord injury is learning to perform self-urinary
catheterization before being discharge to home. The statement made by the
patient that indicates more instruction is needed is: – ANSWER
“It is a sterile procedure”
An adult male patient who cannot void has an order to have a urinary catheter
inserted. Which size catheter would be most appropriate to use? – ANSWER
18 French
An ambulatory clinic patient telephones to report diarrhea and to ask for advice
on medication to manage it. The best response by the nurse is, “Do not use
antidiarrheal medication for longer than___hours without calling back for an
appointment.” – ANSWER 48
A nurse begins the shift caring for a patient who has just returned from the
recovery room after surgery. It is most important to document: – ANSWER
An initial assessment of the patient and a plan based on the needs of the patient
as assessed at the beginning of the shift.
A nurse caring for a patient with a tracheostomy should determine whether the
patient needs suctioning by: – ANSWER Auscultating
breath sounds
A nurse has performed abdominal assessments on four patients. After reviewing
the findings, the nurse is least concerned about problems with bowel elimination
for the patient with abdomen_____bowel sounds in all four quadrants. –
ANSWER Nondistended, soft, with active.
Exam 2: NUR160 / NUR 160 (Latest 2023/
2024) Fundamental Concepts of Practical
Nursing II Exam Review | Questions and
Verified Answers| Already Graded A|
Hondros College
The nurse assisting a weak patient from a bed to the wheelchair to go to physical
therapy would
A. place the wheelchair parallel to the bed and on the patient’s strong side
B. place hands under the patient’s elbows to assist in rising
C. lock knees as the patient is lowered to the chair
D. keep feet close together and twist to put patient in wheelchair – ANSWER
place the wheelchair parallel to the bed and on the patient’s strong side
The nurse uses professional knowledge about body mechanics to prevent the
most common occupational disorder in nurses, which is:
a. carpal tunnel syndrome from use of computer keyboards in nursing
documentation.
b. shoulder and elbow injuries from moving patients.
c. knee injuries from standing for long periods.
d. back injuries from lifting and twisting. – ANSWER
back injuries from lifting and twisting.
The nurse assisting a weak patient from a bed to the wheelchair to go to physical
therapy would:
a. seat the patient on the side of the bed with feet touching the floor.
b. place hands under the patient’s elbows to assist in rising.
c. lock knees as the patient is lowered to the chair.
d. assist the patient to don a robe after being seated in the wheelchair. –
ANSWER seat the patient on the side of the bed with feet
touching the floor.
A frail older patient is able to stand but not to ambulate. She has an order to be
up in a wheelchair as desired during the day. A safe and appropriate way to assist
her up to a chair is to:
a. use a mechanical lift to transfer her from the bed to a chair.
b. assist her to stand and pivot to a chair at right angles to the bed, using a
transfer belt.
c. have another staff member help lift her out of bed to the chair on the count of
three.
d. place a chair close to the bed and use a slide board to slide her into it. –
ANSWER assist her to stand and pivot to a chair at right
angles to the bed, using a transfer belt.
The charge nurse on the night shift of a skilled nursing facility is orienting a new
aide to the unit. The LPN’s most accurate information relative to moving patients
is:
a. “Most of your assigned patients are able to move about a little. Don’t wake
them to change their positions in bed if they are sleeping.”
b. “When you get Mrs. S up to the toilet, be sure to keep your feet together and
your knees locked, or she will pull you over.”
c. “Get one other aide to help and use the mechanical lift when you get Mr. A. out
of bed in the morning. He is heavy and doesn’t assist at all.”
d. “Use your back muscles to lift—that will strengthen them and make it easier for
you to lift or move heavy patients.” – ANSWER “Get one
other aide to help and use the mechanical lift when you get Mr. A. out of bed in
the morning. He is heavy and doesn’t assist at all.”
The patient for whom passive range of motion exercises would be most beneficial
would be the:
a. 66-year-old patient with loss of mobility related to a recent cerebrovascular
accident (CVA).
b. 72-year-old patient with chronic dementia who alternately sits in his
wheelchair and wanders around the unit.
c. 80-year-old patient with chronic lung disease who can breathe only when he is
sitting in a tripod position.
d. 94-year-old patient with increasing fatigue and weight loss who needs
assistance to ambulate. – ANSWER 66-year-old patient
with loss of mobility related to a recent cerebrovascular accident (CVA).
An emaciated semiconscious bed bound patient does not remain in a side lying
position and repeatedly turns onto her back, where she is developing a pressure
area over her sacrum. The nurse should add to the nursing care plan to:
a. raise the knees to keep the patient from sliding down.
b. position the patient on her side and use protective wrist and vest devices to
keep her from turning onto her back.
c. assist the patient to sit in a wheelchair for short periods before returning her to
bed.
d. place the patient on her stomach (prone position) using a small pillow below
her diaphragm – ANSWER place the patient on her
stomach (prone position) using a small pillow below her diaphragm
To provide correct body alignment for a physically immobile patient in bed in the
supine position, the nurse:
a. uses trochanter rolls between the patient’s legs to prevent inward rotation.
b. places a large pillow behind the patient’s head and neck to hyperflex the neck.
c. raises the head and knees to maintain as much flexion of the hips and knees as
possible.
d. uses a footboard or places high top sneakers on the patient’s feet to maintain
dorsiflexion. – ANSWER uses a footboard or places high
top sneakers on the patient’s feet to maintain dorsiflexion.
To place a patient in the Sims’ or lateral lying position, the nurse would initially:
a. raise the head of the bed to a 45- or 60-degree angle.
b. raise the bed to a waist high working level.
c. bring the patient to the edge of the bed so that she will be centered when
turned on
her side.
d. place a pillow behind the patient’s back to support her and prevent her from
rolling
Final Exam: NUR160 / NUR 160 (Latest
2023/ 2024) Fundamental Concepts of
Practical Nursing II Exam Review |
Questions and Verified Answers| Already
Graded A| Hondros College
- You’re making the patient assignments for the next shift. On your unit there are
three LPNs, two RNs, and two nursing assistants. Which patients will you assign to
the LPNs?* (SATA)
A. A 68 year-old male patient who is expected to be discharged home with IV
antibiotic therapy.
B. A 25 year-old female patient newly admitted with diabetic ketoacidosis.
C. A 75 year-old male patient with dementia who has an ileostomy and scheduled
tube feedings.
D. A 65 year-old female patient who has a order to remove the Foley catheter. –
ANSWER C. A 75 year-old male patient with dementia
who has an ileostomy and scheduled tube feedings.
D. A 65 year-old female patient who has a order to remove the Foley catheter.
Answers are C and D. Option A: An RN is the best for this patient because the
patient will need discharge teaching AND the nurse will need to teach the patient
how to self-administer antibiotics. Option B: This is a new admission and the
patient is UNSTABLE. Most patients with DKA (diabetic ketoacidosis) require
insulin drips along with close monitoring of the blood glucose levels, which
requires critical thinking and interpretation. Options C and D are best for the
LPNs: these are standard routine procedures the LPN can perform and these patient
cases are stable. - As the registered nurse, which tasks below should you NOT delegate to the
LPN?* (SATA)
A. Performing an assessment on a new admission
B. Collecting a urine sample from an indwelling Foley catheter
C. Developing a plan of care for a patient who is admitted with Guillain-Barré
Syndrome
D. Educating a patient about how to monitor for side effects associated with
Warfarin
E. Auscultating lung and bowel sounds
F. Starting a blood transfusion
G. Administering IV Morphine 2 mg for pain
H. Providing wound care to a stage 3 pressure injury – ANSWER
A. Performing an assessment on a new admission
C. Developing a plan of care for a patient who is admitted with Guillain-Barré
Syndrome
D. Educating a patient about how to monitor for side effects associated with
Warfarin
F. Starting a blood transfusion
G. Administering IV Morphine 2 mg for pain
Answers are A, C, D, F, G….these are all out of the scope of practice for an LPN.
Remember anything that deals with assessments, educating, evaluating, developing
a plan of care, IV medications, unstable patients, or invasive/complex procedures
where there is unpredictability the RN is responsible for doing it, and these tasks
can’t be delegated. An LPN can perform a focused assessment by listening to lung
or bowel sounds and report the findings to the RN but a comprehensive assessment
is done by the RN. In addition, the LPN can perform standard procedures that are
predictable on stable patients like wound care for a pressure injury, Foley catheter
insertion, obtaining an EKG, obtaining blood glucose level etc.
- On your unit there are two RNs: one is a new RN while the other is an
experienced RN. In addition, there are three LPNs and two nursing assistants.
Which tasks delegated to one of the nursing assistants by the new RN needs to be
re-evaluated?* (SATA)
A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath.
B. Assist the patient with administering a Fleet Enema.
C. Empty an ostomy bag.
D. Collect and record patient’s blood pressure, heart rate, temperature, oxygen
saturation, respirations, and pain rating.
E. Assist a patient with ambulating. – ANSWER A.
Apply hydrocortisone cream to eczema on skin after giving the patient a bath.
B. Assist the patient with administering a Fleet Enema.
Answers: A and B Option A is a task for an LPN or RN…hydrocortisone cream is a
medication and the nursing assistant can’t administer medications. Option B: is a
task for an LPN or RN….it is a procedure. Option C, D, and E are all delegated
tasks a nursing assistant can perform. - When delegating you know that as an RN you must follow the 5 Rights of
Delegation to make sure you are delegating properly. Select all the 5 Rights of
Delegation:* (SATA)
A. Right Credentials
B. Right Direction/Communication
C. Right Supervision
D. Right Experience
E. Right Task
F. Right Person
G. Right Patient
H. Right Circumstance
I. Right Time
J. Right Order – ANSWER B. Right
Direction/Communication
C. Right Supervision
E. Right Task
F. Right Person
H. Right Circumstance
The answers are: B, C, E, F, and H. The 5 Rights of Delegation are: Right Task,
Right Circumstance, Right Person, Right Direction/Communication, and Right
Supervision.