NUR 3300 Final Exam V2 | NUR 3300
Nursing Practice II | Q&A with Rationale
(NUR3300 Final Exam) | William Paterson
University
1. A nurse is caring for a patient who is 24 hours post-abdominal surgery. The patient reports
sudden shortness of breath and chest pain. Which of the following is the priority nursing
action?
A. Administer the prescribed PRN pain medication.
B. Place the patient in High-Fowler’s position and apply oxygen.
C. Perform a complete head-to-toe physical assessment.
D. Notify the surgeon immediately to report the change in status.
Answer: B
Rationale: Sudden shortness of breath and chest pain in a post-operative patient are
indicative of a pulmonary embolism, which is a medical emergency. Placing the patient in
High-Fowler’s position helps maximize lung expansion and ease the work of breathing
while supplemental oxygen addresses potential hypoxia. The nurse must prioritize airway
and breathing (ABC) before contacting the provider or administering medications.
2. When administering a loop diuretic such as Furosemide (Lasix) to a patient with heart
failure, which laboratory value should the nurse monitor most closely?
A. Serum Potassium
,B. Serum Sodium
C. Blood Urea Nitrogen (BUN)
D. Serum Calcium
Answer: A
Rationale: Loop diuretics like Furosemide promote the excretion of water, sodium, and
potassium, which significantly increases the risk for hypokalemia. Low potassium levels
can lead to dangerous cardiac arrhythmias and muscle weakness, requiring vigilant
monitoring by the nursing staff. The nurse should also encourage the intake of potassium-
rich foods or administer supplements as prescribed to maintain electrolyte balance.
3. A patient with Type 1 Diabetes Mellitus presents with a blood glucose of 58 mg/dL and
reports feeling shaky and diaphoretic. Which action should the nurse take first?
A. Administer 15 grams of simple carbohydrates.
B. Administer 10 units of regular insulin subcutaneous.
C. Call the laboratory to verify the capillary glucose reading.
D. Provide a complex carbohydrate and protein snack.
Answer: A
Rationale: The patient is exhibiting symptoms of hypoglycemia, which requires immediate
intervention to raise blood glucose levels. Following the ‘Rule of 15,’ the nurse should
provide 15 grams of rapidly absorbed carbohydrates, such as 4 ounces of orange juice or
,glucose tabs. Once the blood sugar stabilizes above 70 mg/dL, a follow-up snack with
protein and complex carbs is appropriate to maintain stability.
4. Which assessment finding is the most reliable early indicator of deteriorating neurological
status in a patient with a head injury?
A. Dilation of the pupils
B. Change in the level of consciousness
C. Decrease in the heart rate
D. Increase in systolic blood pressure
Answer: B
Rationale: A change in the level of consciousness (LOC) is the most sensitive and earliest
sign of increasing intracranial pressure or neurological decline. While changes in vital
signs, such as Cushing’s Triad, occur eventually, they are typically late signs of brain
herniation. The nurse should utilize the Glasgow Coma Scale (GCS) for objective and
consistent monitoring of neurological responses.
5. A nurse is providing discharge education for a patient newly diagnosed with Chronic
Obstructive Pulmonary Disease (COPD). Which statement by the patient indicates a need for
further teaching?
A. “I will increase my oxygen flow rate to 6L/min if I feel winded.”
B. “I should eat small, frequent, high-calorie meals throughout the day.”
C. “I will practice pursed-lip breathing when I feel short of breath.”
, D. “I need to receive the annual influenza and pneumococcal vaccines.”
Answer: A
Rationale: In patients with COPD, a high flow rate of oxygen can suppress the hypoxic
drive, leading to carbon dioxide retention and respiratory failure. Patients are generally
advised to maintain oxygen saturation levels between 88% and 92% rather than aiming for
100%. The other statements correctly reflect nutritional management, breathing
techniques, and infection prevention strategies for COPD.
6. The nurse is assessing a patient with Right-Sided Heart Failure. Which of the following
clinical manifestations is the nurse most likely to observe?
A. Jugular venous distension (JVD)
B. Pulmonary crackles and wheezing
C. Paroxysmal nocturnal dyspnea
D. Pink, frothy sputum
Answer: A
Rationale: Right-sided heart failure results in systemic venous congestion because the
right ventricle cannot effectively pump blood into the lungs. This leads to clinical signs such
as jugular venous distension, peripheral edema, and hepatomegaly. Symptoms like crackles
and frothy sputum are characteristic of left-sided heart failure, where blood backs up into
the pulmonary circulation.
Nursing Practice II | Q&A with Rationale
(NUR3300 Final Exam) | William Paterson
University
1. A nurse is caring for a patient who is 24 hours post-abdominal surgery. The patient reports
sudden shortness of breath and chest pain. Which of the following is the priority nursing
action?
A. Administer the prescribed PRN pain medication.
B. Place the patient in High-Fowler’s position and apply oxygen.
C. Perform a complete head-to-toe physical assessment.
D. Notify the surgeon immediately to report the change in status.
Answer: B
Rationale: Sudden shortness of breath and chest pain in a post-operative patient are
indicative of a pulmonary embolism, which is a medical emergency. Placing the patient in
High-Fowler’s position helps maximize lung expansion and ease the work of breathing
while supplemental oxygen addresses potential hypoxia. The nurse must prioritize airway
and breathing (ABC) before contacting the provider or administering medications.
2. When administering a loop diuretic such as Furosemide (Lasix) to a patient with heart
failure, which laboratory value should the nurse monitor most closely?
A. Serum Potassium
,B. Serum Sodium
C. Blood Urea Nitrogen (BUN)
D. Serum Calcium
Answer: A
Rationale: Loop diuretics like Furosemide promote the excretion of water, sodium, and
potassium, which significantly increases the risk for hypokalemia. Low potassium levels
can lead to dangerous cardiac arrhythmias and muscle weakness, requiring vigilant
monitoring by the nursing staff. The nurse should also encourage the intake of potassium-
rich foods or administer supplements as prescribed to maintain electrolyte balance.
3. A patient with Type 1 Diabetes Mellitus presents with a blood glucose of 58 mg/dL and
reports feeling shaky and diaphoretic. Which action should the nurse take first?
A. Administer 15 grams of simple carbohydrates.
B. Administer 10 units of regular insulin subcutaneous.
C. Call the laboratory to verify the capillary glucose reading.
D. Provide a complex carbohydrate and protein snack.
Answer: A
Rationale: The patient is exhibiting symptoms of hypoglycemia, which requires immediate
intervention to raise blood glucose levels. Following the ‘Rule of 15,’ the nurse should
provide 15 grams of rapidly absorbed carbohydrates, such as 4 ounces of orange juice or
,glucose tabs. Once the blood sugar stabilizes above 70 mg/dL, a follow-up snack with
protein and complex carbs is appropriate to maintain stability.
4. Which assessment finding is the most reliable early indicator of deteriorating neurological
status in a patient with a head injury?
A. Dilation of the pupils
B. Change in the level of consciousness
C. Decrease in the heart rate
D. Increase in systolic blood pressure
Answer: B
Rationale: A change in the level of consciousness (LOC) is the most sensitive and earliest
sign of increasing intracranial pressure or neurological decline. While changes in vital
signs, such as Cushing’s Triad, occur eventually, they are typically late signs of brain
herniation. The nurse should utilize the Glasgow Coma Scale (GCS) for objective and
consistent monitoring of neurological responses.
5. A nurse is providing discharge education for a patient newly diagnosed with Chronic
Obstructive Pulmonary Disease (COPD). Which statement by the patient indicates a need for
further teaching?
A. “I will increase my oxygen flow rate to 6L/min if I feel winded.”
B. “I should eat small, frequent, high-calorie meals throughout the day.”
C. “I will practice pursed-lip breathing when I feel short of breath.”
, D. “I need to receive the annual influenza and pneumococcal vaccines.”
Answer: A
Rationale: In patients with COPD, a high flow rate of oxygen can suppress the hypoxic
drive, leading to carbon dioxide retention and respiratory failure. Patients are generally
advised to maintain oxygen saturation levels between 88% and 92% rather than aiming for
100%. The other statements correctly reflect nutritional management, breathing
techniques, and infection prevention strategies for COPD.
6. The nurse is assessing a patient with Right-Sided Heart Failure. Which of the following
clinical manifestations is the nurse most likely to observe?
A. Jugular venous distension (JVD)
B. Pulmonary crackles and wheezing
C. Paroxysmal nocturnal dyspnea
D. Pink, frothy sputum
Answer: A
Rationale: Right-sided heart failure results in systemic venous congestion because the
right ventricle cannot effectively pump blood into the lungs. This leads to clinical signs such
as jugular venous distension, peripheral edema, and hepatomegaly. Symptoms like crackles
and frothy sputum are characteristic of left-sided heart failure, where blood backs up into
the pulmonary circulation.
