Question

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a non- modifiable risk factor for disease?

Answer 1

Correct Answers:

Genetics

Rationale :

➡️Genetic makeup is a non-modifiable risk factor, meaning it cannot be changed or influenced by lifestyle or environment.

➡️Hereditary conditions such as diabetes mellitus, hypertension, or certain cancers may run in families due to shared genetic traits.

➡️Identifying genetic risk helps in preventive screening and early intervention.

➡️Unlike smoking, poor diet, or sun exposure, genetic predisposition is inherent and lifelong.

➡️Nurses use this information for patient education about modifiable habits that can lower overall disease risk.

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Answer 2

Correct Answers:

Infiltration

Rationale :

🟠Infiltration occurs when IV fluid leaks into the surrounding tissue due to dislodged or damaged cannula.

🟠Early signs include edema, erythema, and burning or discomfort at the insertion site, as seen in this client.

🟠The affected area may feel cool or firm and show slowed infusion rate.

🟠Immediate nursing actions include stopping the infusion, removing the catheter, elevating the limb, and applying a warm compress.

🟠Timely recognition prevents tissue injury and compromised circulation.

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Answer 3

Correct Answers:

To identify and resolve discrepancies in the patient's medication list.

Rationale :

♦️Medication reconciliation ensures that a patient’s medication list is accurate and consistent across care transitions.

♦️The process compares home, hospital, and discharge medications to avoid omissions, duplications, or drug interactions.

♦️This improves patient safety by reducing medication errors.

♦️Nurses play a key role by verifying current medications, doses, and frequencies with the patient or caregiver.

♦️It supports continuity of care and safe pharmacologic management.

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Answer 4

Correct Answers:

Hypertension.

Rationale :

✔️In the early stages of hypoxia, the body compensates by increasing heart rate and blood pressure to deliver more oxygen to tissues.

✔️This response results in tachycardia and hypertension rather than bradycardia or cyanosis (which appear later).

✔️Other early signs include anxiety, restlessness, and confusion.

✔️As hypoxia progresses, vital signs decline, and cyanosis develops.

✔️Recognizing these early compensatory signs enables timely oxygen intervention before severe hypoxemia develops.

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Answer 5

Correct Answers:

Restlessness.

Rationale :

✍️ Restlessness is one of the earliest clinical indicators of inadequate oxygenation or decreased tissue perfusion.

✍️Low oxygen levels affect brain function first, causing anxiety, irritability, or agitation.

✍️If not corrected, it can progress to dyspnea, retractions, and cyanosis.

✍️Nurses should promptly check oxygen saturation, airway patency, and respiratory effort when restlessness occurs.

✍️Early recognition allows for interventions to prevent hypoxic organ damage.

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Answer 6

Correct Answers:

Repeat the auscultation after asking the client to breathe deeply and cough.

Rationale :

✅Crackles may result from accumulated secretions in the airways, especially in postoperative or immobilized clients.

✅Encouraging deep breathing and coughing helps mobilize mucus and re-expand alveoli.

✅Reassessing after this intervention helps determine whether the sounds were transient or pathological.

✅If crackles persist, it may indicate fluid overload or infection requiring further evaluation.

✅This action is noninvasive, safe, and essential for accurate respiratory assessment.

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Answer 7

Correct Answers:

4 to 14 hr

Rationale :

🟣NPH insulin (intermediate-acting) has an onset of 1–2 hours, peak between 4–14 hours, and duration up to 24 hours.

🟣The peak is the period of maximum hypoglycemic effect, requiring close monitoring for low blood glucose symptoms.

🟣Providing meals or snacks during the peak window helps prevent hypoglycemia.

🟣Understanding insulin pharmacokinetics is crucial for safe timing of meals and activity.

🟣Nurses must educate clients on recognizing and managing signs of hypoglycemia (e.g., tremors, sweating, confusion).

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Answer 8

Correct Answers:

Red line

Rationale :

➡️Phlebitis is inflammation of a vein caused by mechanical, chemical, or bacterial irritation.

➡️A red line or streak along the vein path is a classic visible manifestation.

➡️Other signs include localized warmth, tenderness, and swelling.

➡️If phlebitis occurs, the nurse should discontinue the IV, apply warm compresses, and document findings.

➡️Preventive measures include rotating IV sites and using appropriate gauge catheters.

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Answer 9

Correct Answers:

Do not recap the needle on an ABG specimen.

Rationale :

🩸Recapping used needles significantly increases the risk of needlestick injuries and bloodborne pathogen transmission.

🩸The safest practice is to immediately dispose of uncapped needles into a puncture-proof sharps container.

🩸This follows OSHA and CDC safety guidelines for infection prevention.

🩸Nurses should handle sharps minimally and avoid any unnecessary manipulation.

🩸Consistent adherence protects both healthcare workers and clients from HIV, hepatitis B, and C exposure.

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Answer 10

Correct Answers:

Pinch the skin up at the chosen site with the nondominant hand before inserting the needle.

Rationale :

◼️For intradermal injections, pinching the skin creates a taut surface and controls depth of insertion into the dermis.

◼️This ensures accurate placement of small doses (0.1 mL or less) such as for tuberculin or allergy testing.

◼️The needle should be inserted at a 10–15° angle, bevel up, forming a small wheal or bleb.

◼️Proper technique ensures consistent absorption and accurate test results.

◼️The injection site (inner forearm) must remain uncovered and unmassaged post-injection to prevent dispersion.

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Custom Fundamentals unit Exam 2 Fall 2025

No.

1 :
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a non- modifiable risk factor for disease?

2 :
A nurse is attending to 72-year old non-compliant diabetic patient receiving a continuous IVF infusion. The patient complains of a burning sensation at the now edematic cannulation site with noticeable erythema. Considering the symptoms reported, what is the most obvious conclusion?

3 :
Which of the following is a primary goal of medication reconciliation?

4 :
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?

5 :
A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?

6 :
When auscultating a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?

7 :
A nurse is preparing to administer a client's daily dose of NPH insulin at 0730. The nurse should expect this type of insulin to peak within which of the following timeframes after administration?

8 :
Which of the following is a manifestation of phlebitis?

9 :
A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needlestick injuries. Which of the following actions should the nurse recommend?

10 :
A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. Which of the following actions should the nurse plan to take?

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Custom Fundamentals unit Exam 2 Fall 2025

No.

1 : A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a non- modifiable risk factor for disease?

2 : A nurse is attending to 72-year old non-compliant diabetic patient receiving a continuous IVF infusion. The patient complains of a burning sensation at the now edematic cannulation site with noticeable erythema. Considering the symptoms reported, what is the most obvious conclusion?

3 : Which of the following is a primary goal of medication reconciliation?

4 : A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?

5 : A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?

6 : When auscultating a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?

7 : A nurse is preparing to administer a client's daily dose of NPH insulin at 0730. The nurse should expect this type of insulin to peak within which of the following timeframes after administration?

8 : Which of the following is a manifestation of phlebitis?

9 : A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needlestick injuries. Which of the following actions should the nurse recommend?

10 : A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. Which of the following actions should the nurse plan to take?

1 :
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a non- modifiable risk factor for disease?

2 :
A nurse is attending to 72-year old non-compliant diabetic patient receiving a continuous IVF infusion. The patient complains of a burning sensation at the now edematic cannulation site with noticeable erythema. Considering the symptoms reported, what is the most obvious conclusion?

3 :
Which of the following is a primary goal of medication reconciliation?

4 :
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?

5 :
A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?

6 :
When auscultating a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?

7 :
A nurse is preparing to administer a client's daily dose of NPH insulin at 0730. The nurse should expect this type of insulin to peak within which of the following timeframes after administration?

8 :
Which of the following is a manifestation of phlebitis?

9 :
A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needlestick injuries. Which of the following actions should the nurse recommend?

10 :
A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. Which of the following actions should the nurse plan to take?