NUR 170 Final Exam V1 | NUR 2214
Nursing Care of the Older Adult | Actual
Q&A with Rationale (NUR2214 Week 1
Quiz) | Rasmussen University
1. A nurse is caring for a patient with a potassium level of 3.2 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Increased bowel sounds
B. Hyperreflexia
C. Cardiac dysrhythmias
D. Muscle twitching
Answer: C
Rationale: A potassium level of 3.2 mEq/L indicates hypokalemia, which significantly
increases the risk of life-threatening cardiac dysrhythmias. The nurse must prioritize
cardiac monitoring to detect changes in the EKG rhythm immediately. While muscle
weakness can occur, cardiac stability is the primary concern for patient safety.
2. Which action by the nurse is most appropriate when witnessing a patient sign a surgical
informed consent form?
A. Confirming the nurse has explained the risks and benefits of the procedure
B. Ensuring the patient is signing the form voluntarily
,C. Describing the surgical technique to the patient in detail
D. Updating the patient on the expected recovery time
Answer: B
Rationale: The nurse’s primary role in the consent process is to witness the patient’s
signature and verify that the consent is voluntary. It is the surgeon’s responsibility, not the
nurse’s, to explain the procedure, risks, and benefits to the patient. If the nurse identifies
that the patient does not understand the procedure, the surgeon must be notified to
provide further clarification.
3. A patient with COPD is receiving oxygen therapy. What is the target oxygen saturation
range the nurse should maintain to prevent respiratory depression?
A. 95% to 100%
B. 88% to 92%
C. 92% to 96%
D. 85% to 88%
Answer: B
Rationale: In patients with chronic obstructive pulmonary disease, high levels of oxygen
can suppress the hypoxic drive to breathe. Maintaining an oxygen saturation between 88%
and 92% is generally recommended for these patients to avoid carbon dioxide retention.
The nurse should titrate oxygen carefully to ensure adequate oxygenation without causing
respiratory failure.
, 4. The nurse is assessing a patient with suspected left-sided heart failure. Which lung sound is
most indicative of this condition?
A. Crackles
B. Stridor
C. Rhonchi
D. Wheezing
Answer: A
Rationale: Left-sided heart failure leads to pulmonary congestion because the heart cannot
effectively pump blood into the systemic circulation. This fluid backup results in crackles,
which are typically heard at the base of the lungs during inspiration. The nurse must
monitor breath sounds frequently to assess for worsening pulmonary edema.
5. A patient with Type 1 Diabetes Mellitus presents with diaphoresis, tremors, and confusion.
Which action should the nurse take first?
A. Administer 15 grams of fast-acting carbohydrates
B. Check the patient’s blood glucose level
C. Give a scheduled dose of long-acting insulin
D. Call the rapid response team
Answer: B
Nursing Care of the Older Adult | Actual
Q&A with Rationale (NUR2214 Week 1
Quiz) | Rasmussen University
1. A nurse is caring for a patient with a potassium level of 3.2 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Increased bowel sounds
B. Hyperreflexia
C. Cardiac dysrhythmias
D. Muscle twitching
Answer: C
Rationale: A potassium level of 3.2 mEq/L indicates hypokalemia, which significantly
increases the risk of life-threatening cardiac dysrhythmias. The nurse must prioritize
cardiac monitoring to detect changes in the EKG rhythm immediately. While muscle
weakness can occur, cardiac stability is the primary concern for patient safety.
2. Which action by the nurse is most appropriate when witnessing a patient sign a surgical
informed consent form?
A. Confirming the nurse has explained the risks and benefits of the procedure
B. Ensuring the patient is signing the form voluntarily
,C. Describing the surgical technique to the patient in detail
D. Updating the patient on the expected recovery time
Answer: B
Rationale: The nurse’s primary role in the consent process is to witness the patient’s
signature and verify that the consent is voluntary. It is the surgeon’s responsibility, not the
nurse’s, to explain the procedure, risks, and benefits to the patient. If the nurse identifies
that the patient does not understand the procedure, the surgeon must be notified to
provide further clarification.
3. A patient with COPD is receiving oxygen therapy. What is the target oxygen saturation
range the nurse should maintain to prevent respiratory depression?
A. 95% to 100%
B. 88% to 92%
C. 92% to 96%
D. 85% to 88%
Answer: B
Rationale: In patients with chronic obstructive pulmonary disease, high levels of oxygen
can suppress the hypoxic drive to breathe. Maintaining an oxygen saturation between 88%
and 92% is generally recommended for these patients to avoid carbon dioxide retention.
The nurse should titrate oxygen carefully to ensure adequate oxygenation without causing
respiratory failure.
, 4. The nurse is assessing a patient with suspected left-sided heart failure. Which lung sound is
most indicative of this condition?
A. Crackles
B. Stridor
C. Rhonchi
D. Wheezing
Answer: A
Rationale: Left-sided heart failure leads to pulmonary congestion because the heart cannot
effectively pump blood into the systemic circulation. This fluid backup results in crackles,
which are typically heard at the base of the lungs during inspiration. The nurse must
monitor breath sounds frequently to assess for worsening pulmonary edema.
5. A patient with Type 1 Diabetes Mellitus presents with diaphoresis, tremors, and confusion.
Which action should the nurse take first?
A. Administer 15 grams of fast-acting carbohydrates
B. Check the patient’s blood glucose level
C. Give a scheduled dose of long-acting insulin
D. Call the rapid response team
Answer: B
