NUR 2063 EXAM 1 – EXAM-STYLE QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS |
PLUS RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE
TEST
1. A client with a history of heart failure presents with jugular venous distention, peripheral edema, and an
S3 gallop. Which intervention should the nurse anticipate as the priority based on these assessment
findings?
A. Administer a beta-blocker to reduce cardiac workload.
B. Restrict oral fluid intake to 1,000 mL per day.
C. Administer a loop diuretic as prescribed to reduce preload.
D. Prepare the client for a transthoracic echocardiogram.
Correct Answer: C. Administer a loop diuretic as prescribed to reduce preload.
Rationale: The client's assessment findings of jugular venous distention, peripheral edema, and an S3 gallop are
classic signs of fluid volume overload and worsening heart failure. The priority intervention is to reduce preload,
which is effectively achieved with a loop diuretic like furosemide. While a beta-blocker is a maintenance
therapy, it is not the priority in acute fluid overload. Fluid restriction is important but secondary to
pharmacological intervention for immediate symptom relief. An echocardiogram is a diagnostic tool used to
assess cardiac function, but it is not the immediate therapeutic priority.
,2. A healthcare provider orders a continuous infusion of regular insulin for a client in diabetic ketoacidosis
(DKA). Which assessment parameter is most critical for the nurse to monitor every hour during this
infusion?
A. Serum potassium levels.
B. Urine output.
C. Blood glucose levels.
D. Level of consciousness.
Correct Answer: A. Serum potassium levels.
Rationale: While all options are important in managing DKA, monitoring serum potassium is the most critical
hourly parameter. Insulin administration drives potassium into the cells, which can cause rapid and potentially
fatal hypokalemia. Blood glucose is typically monitored hourly but is often reduced in frequency after the initial
drop. Urine output and level of consciousness are important assessments but do not carry the same immediate
life-threatening risk as a rapidly falling potassium level during insulin therapy.
3. A nurse is providing discharge teaching to a client prescribed warfarin. Which statement by the client
indicates a need for further education?
A. "I will use a soft-bristled toothbrush to prevent gum bleeding."
B. "I should avoid eating large amounts of green leafy vegetables."
,C. "I will take an over-the-counter proton pump inhibitor for occasional heartburn."
D. "I will check my skin for bruising more frequently."
Correct Answer: C. "I will take an over-the-counter proton pump inhibitor for occasional heartburn."
Rationale: Clients on warfarin should avoid over-the-counter medications without consulting their healthcare
provider, as many drugs can interact and alter the INR. Proton pump inhibitors (PPIs) have been shown to have
a potential interaction with warfarin, affecting its metabolism and increasing the risk of bleeding. The other
statements are correct, as they reflect proper knowledge of bleeding precautions, dietary modifications
regarding vitamin K intake, and monitoring for adverse effects.
4. A client with chronic obstructive pulmonary disease (COPD) has an arterial blood gas (ABG) result
showing pH 7.32, PaCO2 58 mmHg, and HCO3- 30 mEq/L. The nurse interprets these results as indicating
which condition?
A. Metabolic acidosis with respiratory compensation.
B. Respiratory acidosis with metabolic compensation.
C. Metabolic alkalosis with respiratory compensation.
D. Respiratory alkalosis with metabolic compensation.
Correct Answer: B. Respiratory acidosis with metabolic compensation.
, Rationale: The ABG shows a low pH (acidemia), an elevated PaCO2 (indicating a respiratory cause for the
acidosis), and an elevated HCO3-, which is the compensatory response. This pattern is consistent with chronic
respiratory acidosis, where the kidneys have retained bicarbonate to buffer the acidotic state. In metabolic
acidosis, the pH would be low, but the HCO3- would be the primary abnormality. Metabolic alkalosis would
have a high pH, and respiratory alkalosis would have a low PaCO2.
5. During a home visit, a nurse assesses a client recovering from a myocardial infarction. The client
expresses feelings of anxiety and fear about returning to work. What is the nurse's most appropriate
therapeutic response?
A. "You should focus on your recovery first and worry about work later."
B. "Many people feel the same way after a heart attack. Tell me more about your specific concerns."
C. "I can speak with your cardiologist about a referral to a vocational counselor."
D. "Your health is the priority, and you should avoid any stress related to your job."
Correct Answer: B. "Many people feel the same way after a heart attack. Tell me more about your specific
concerns."
Rationale: This response is therapeutic as it validates the client's feelings by normalizing them, which reduces
anxiety and encourages further expression. It opens the door for the client to discuss specific concerns, allowing
the nurse to assess the situation more thoroughly. The other options are either dismissive of the client's feelings,
PLUS RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE
TEST
1. A client with a history of heart failure presents with jugular venous distention, peripheral edema, and an
S3 gallop. Which intervention should the nurse anticipate as the priority based on these assessment
findings?
A. Administer a beta-blocker to reduce cardiac workload.
B. Restrict oral fluid intake to 1,000 mL per day.
C. Administer a loop diuretic as prescribed to reduce preload.
D. Prepare the client for a transthoracic echocardiogram.
Correct Answer: C. Administer a loop diuretic as prescribed to reduce preload.
Rationale: The client's assessment findings of jugular venous distention, peripheral edema, and an S3 gallop are
classic signs of fluid volume overload and worsening heart failure. The priority intervention is to reduce preload,
which is effectively achieved with a loop diuretic like furosemide. While a beta-blocker is a maintenance
therapy, it is not the priority in acute fluid overload. Fluid restriction is important but secondary to
pharmacological intervention for immediate symptom relief. An echocardiogram is a diagnostic tool used to
assess cardiac function, but it is not the immediate therapeutic priority.
,2. A healthcare provider orders a continuous infusion of regular insulin for a client in diabetic ketoacidosis
(DKA). Which assessment parameter is most critical for the nurse to monitor every hour during this
infusion?
A. Serum potassium levels.
B. Urine output.
C. Blood glucose levels.
D. Level of consciousness.
Correct Answer: A. Serum potassium levels.
Rationale: While all options are important in managing DKA, monitoring serum potassium is the most critical
hourly parameter. Insulin administration drives potassium into the cells, which can cause rapid and potentially
fatal hypokalemia. Blood glucose is typically monitored hourly but is often reduced in frequency after the initial
drop. Urine output and level of consciousness are important assessments but do not carry the same immediate
life-threatening risk as a rapidly falling potassium level during insulin therapy.
3. A nurse is providing discharge teaching to a client prescribed warfarin. Which statement by the client
indicates a need for further education?
A. "I will use a soft-bristled toothbrush to prevent gum bleeding."
B. "I should avoid eating large amounts of green leafy vegetables."
,C. "I will take an over-the-counter proton pump inhibitor for occasional heartburn."
D. "I will check my skin for bruising more frequently."
Correct Answer: C. "I will take an over-the-counter proton pump inhibitor for occasional heartburn."
Rationale: Clients on warfarin should avoid over-the-counter medications without consulting their healthcare
provider, as many drugs can interact and alter the INR. Proton pump inhibitors (PPIs) have been shown to have
a potential interaction with warfarin, affecting its metabolism and increasing the risk of bleeding. The other
statements are correct, as they reflect proper knowledge of bleeding precautions, dietary modifications
regarding vitamin K intake, and monitoring for adverse effects.
4. A client with chronic obstructive pulmonary disease (COPD) has an arterial blood gas (ABG) result
showing pH 7.32, PaCO2 58 mmHg, and HCO3- 30 mEq/L. The nurse interprets these results as indicating
which condition?
A. Metabolic acidosis with respiratory compensation.
B. Respiratory acidosis with metabolic compensation.
C. Metabolic alkalosis with respiratory compensation.
D. Respiratory alkalosis with metabolic compensation.
Correct Answer: B. Respiratory acidosis with metabolic compensation.
, Rationale: The ABG shows a low pH (acidemia), an elevated PaCO2 (indicating a respiratory cause for the
acidosis), and an elevated HCO3-, which is the compensatory response. This pattern is consistent with chronic
respiratory acidosis, where the kidneys have retained bicarbonate to buffer the acidotic state. In metabolic
acidosis, the pH would be low, but the HCO3- would be the primary abnormality. Metabolic alkalosis would
have a high pH, and respiratory alkalosis would have a low PaCO2.
5. During a home visit, a nurse assesses a client recovering from a myocardial infarction. The client
expresses feelings of anxiety and fear about returning to work. What is the nurse's most appropriate
therapeutic response?
A. "You should focus on your recovery first and worry about work later."
B. "Many people feel the same way after a heart attack. Tell me more about your specific concerns."
C. "I can speak with your cardiologist about a referral to a vocational counselor."
D. "Your health is the priority, and you should avoid any stress related to your job."
Correct Answer: B. "Many people feel the same way after a heart attack. Tell me more about your specific
concerns."
Rationale: This response is therapeutic as it validates the client's feelings by normalizing them, which reduces
anxiety and encourages further expression. It opens the door for the client to discuss specific concerns, allowing
the nurse to assess the situation more thoroughly. The other options are either dismissive of the client's feelings,
