NURS 6551 FINAL EXAM] – QUESTIONS AND ANSWERS |
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
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1. A 68-year-old patient with a history of heart failure presents with increased dyspnea and
peripheral edema. Which assessment finding best indicates an exacerbation of fluid
overload?
A. Blood pressure of 110/70 mmHg
B. Distended jugular veins at 45 degrees
C. Clear lung sounds upon auscultation
D. Weight loss of 0.5 kg overnight
Jugular venous distention is a classic clinical indicator of elevated central venous pressure
and systemic fluid overload in patients with heart failure. Options A, C, and D are inconsistent
with a fluid volume overload state.
2. When developing a plan of care for a patient with newly diagnosed Type 2 diabetes,
which intervention should the nurse prioritize to promote long-term glycemic control?
A. Strict adherence to a 1200-calorie diet
B. Education on self-monitoring of blood glucose
C. Immediate initiation of insulin therapy
D. Elimination of all complex carbohydrates
Empowering the patient with self-management skills, particularly blood glucose monitoring,
is the cornerstone of long-term glycemic management. Dietary modifications should be
individualized rather than overly restrictive, and insulin is not always the first-line treatment.
3. A nurse is evaluating the effectiveness of a teaching session regarding hypertension
management. Which statement by the patient indicates an understanding of the DASH
diet?
A. I will increase my intake of processed meats
B. I will focus on consuming more whole grains, fruits, and vegetables
C. I will eliminate all fats from my diet
D. I will limit my fluid intake to 1 liter per day
The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes fruits, vegetables,
whole grains, and lean proteins while limiting sodium and saturated fats.
4. A patient reports severe pain after a total hip arthroplasty. Which action by the nurse is
most appropriate for initial assessment?
,A. Administering the prescribed PRN analgesic immediately
B. Assessing the surgical site for signs of infection
C. Using a validated pain scale to quantify the patient's discomfort
D. Repositioning the patient without assessing the pain first
Pain is subjective; therefore, the nurse must first quantify the intensity and characteristics of
the pain using a validated scale before intervening or performing further assessments.
5. Which laboratory finding would the nurse expect to see in a patient presenting with
acute dehydration?
A. Decreased hematocrit
B. Elevated serum sodium
C. Decreased blood urea nitrogen (BUN)
D. Elevated potassium levels
Dehydration results in hemoconcentration, often leading to hypernatremia due to the loss of
free water relative to sodium. Hematocrit and BUN typically increase, not decrease, in
dehydrated states.
6. A nurse is caring for a patient experiencing a panic attack. Which intervention is the
most effective nursing action?
A. Leaving the patient alone to reduce stimuli
B. Using short, simple sentences and maintaining a calm demeanor
C. Encouraging the patient to identify the exact cause of the attack
D. Administering a sedative immediately
During a panic attack, a patient's ability to process complex information is severely limited. A
calm, directive, and simple communication style provides safety and reduces anxiety.
7. Which instruction is essential when discharging a patient on warfarin therapy?
A. Increase intake of green leafy vegetables
B. Report any unexplained bruising or bleeding immediately
C. Take the medication only when feeling symptomatic
D. Avoid all forms of physical activity
Warfarin is an anticoagulant that increases bleeding risk. Patients must monitor for signs of
hemorrhage. Green leafy vegetables contain Vitamin K and should be kept consistent in the
diet, not increased.
8. A patient is prescribed a beta-blocker for management of hypertension. Which
assessment finding would require the nurse to hold the medication?
A. Heart rate of 52 beats per minute
, B. Blood pressure of 138/86 mmHg
C. Respiratory rate of 18 breaths per minute
D. Patient report of mild fatigue
Beta-blockers slow the heart rate. A heart rate below 60 bpm is a standard clinical threshold
for holding beta-blockers to prevent symptomatic bradycardia.
9. Which diagnostic test is the gold standard for confirming a diagnosis of pulmonary
embolism?
A. Chest X-ray
B. Arterial blood gas
C. Computed tomography pulmonary angiography (CTPA)
D. Electrocardiogram
CTPA is the definitive imaging modality for visualizing pulmonary emboli in the pulmonary
vasculature. While other tests support the diagnosis, they are not diagnostic for PE.
10. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD).
Which oxygen delivery setting is typically recommended to avoid suppressing the hypoxic
drive?
A. 6-10 L/min via nasal cannula
B. 1-2 L/min via nasal cannula
C. 15 L/min via non-rebreather mask
D. 5 L/min via simple face mask
Patients with long-standing COPD may rely on a hypoxic drive to breathe. High-flow oxygen
can lead to CO2 retention and respiratory depression; therefore, low-flow oxygen is preferred.
11. A nurse is reviewing a patient's morning lab results. Which potassium level should be
reported to the provider immediately?
A. 3.8 mEq/L
B. 4.5 mEq/L
C. 2.9 mEq/L
D. 5.0 mEq/L
Hypokalemia (less than 3.5 mEq/L) can lead to life-threatening cardiac arrhythmias. A level
of 2.9 mEq/L is significantly low and requires urgent clinical attention.
12. When administering a blood transfusion, what is the nurse's priority action if the
patient develops hives and pruritus?
A. Slow the infusion rate
B. Stop the infusion and disconnect the tubing
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST | DOWNLOAD INSTANT PDF
1. A 68-year-old patient with a history of heart failure presents with increased dyspnea and
peripheral edema. Which assessment finding best indicates an exacerbation of fluid
overload?
A. Blood pressure of 110/70 mmHg
B. Distended jugular veins at 45 degrees
C. Clear lung sounds upon auscultation
D. Weight loss of 0.5 kg overnight
Jugular venous distention is a classic clinical indicator of elevated central venous pressure
and systemic fluid overload in patients with heart failure. Options A, C, and D are inconsistent
with a fluid volume overload state.
2. When developing a plan of care for a patient with newly diagnosed Type 2 diabetes,
which intervention should the nurse prioritize to promote long-term glycemic control?
A. Strict adherence to a 1200-calorie diet
B. Education on self-monitoring of blood glucose
C. Immediate initiation of insulin therapy
D. Elimination of all complex carbohydrates
Empowering the patient with self-management skills, particularly blood glucose monitoring,
is the cornerstone of long-term glycemic management. Dietary modifications should be
individualized rather than overly restrictive, and insulin is not always the first-line treatment.
3. A nurse is evaluating the effectiveness of a teaching session regarding hypertension
management. Which statement by the patient indicates an understanding of the DASH
diet?
A. I will increase my intake of processed meats
B. I will focus on consuming more whole grains, fruits, and vegetables
C. I will eliminate all fats from my diet
D. I will limit my fluid intake to 1 liter per day
The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes fruits, vegetables,
whole grains, and lean proteins while limiting sodium and saturated fats.
4. A patient reports severe pain after a total hip arthroplasty. Which action by the nurse is
most appropriate for initial assessment?
,A. Administering the prescribed PRN analgesic immediately
B. Assessing the surgical site for signs of infection
C. Using a validated pain scale to quantify the patient's discomfort
D. Repositioning the patient without assessing the pain first
Pain is subjective; therefore, the nurse must first quantify the intensity and characteristics of
the pain using a validated scale before intervening or performing further assessments.
5. Which laboratory finding would the nurse expect to see in a patient presenting with
acute dehydration?
A. Decreased hematocrit
B. Elevated serum sodium
C. Decreased blood urea nitrogen (BUN)
D. Elevated potassium levels
Dehydration results in hemoconcentration, often leading to hypernatremia due to the loss of
free water relative to sodium. Hematocrit and BUN typically increase, not decrease, in
dehydrated states.
6. A nurse is caring for a patient experiencing a panic attack. Which intervention is the
most effective nursing action?
A. Leaving the patient alone to reduce stimuli
B. Using short, simple sentences and maintaining a calm demeanor
C. Encouraging the patient to identify the exact cause of the attack
D. Administering a sedative immediately
During a panic attack, a patient's ability to process complex information is severely limited. A
calm, directive, and simple communication style provides safety and reduces anxiety.
7. Which instruction is essential when discharging a patient on warfarin therapy?
A. Increase intake of green leafy vegetables
B. Report any unexplained bruising or bleeding immediately
C. Take the medication only when feeling symptomatic
D. Avoid all forms of physical activity
Warfarin is an anticoagulant that increases bleeding risk. Patients must monitor for signs of
hemorrhage. Green leafy vegetables contain Vitamin K and should be kept consistent in the
diet, not increased.
8. A patient is prescribed a beta-blocker for management of hypertension. Which
assessment finding would require the nurse to hold the medication?
A. Heart rate of 52 beats per minute
, B. Blood pressure of 138/86 mmHg
C. Respiratory rate of 18 breaths per minute
D. Patient report of mild fatigue
Beta-blockers slow the heart rate. A heart rate below 60 bpm is a standard clinical threshold
for holding beta-blockers to prevent symptomatic bradycardia.
9. Which diagnostic test is the gold standard for confirming a diagnosis of pulmonary
embolism?
A. Chest X-ray
B. Arterial blood gas
C. Computed tomography pulmonary angiography (CTPA)
D. Electrocardiogram
CTPA is the definitive imaging modality for visualizing pulmonary emboli in the pulmonary
vasculature. While other tests support the diagnosis, they are not diagnostic for PE.
10. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD).
Which oxygen delivery setting is typically recommended to avoid suppressing the hypoxic
drive?
A. 6-10 L/min via nasal cannula
B. 1-2 L/min via nasal cannula
C. 15 L/min via non-rebreather mask
D. 5 L/min via simple face mask
Patients with long-standing COPD may rely on a hypoxic drive to breathe. High-flow oxygen
can lead to CO2 retention and respiratory depression; therefore, low-flow oxygen is preferred.
11. A nurse is reviewing a patient's morning lab results. Which potassium level should be
reported to the provider immediately?
A. 3.8 mEq/L
B. 4.5 mEq/L
C. 2.9 mEq/L
D. 5.0 mEq/L
Hypokalemia (less than 3.5 mEq/L) can lead to life-threatening cardiac arrhythmias. A level
of 2.9 mEq/L is significantly low and requires urgent clinical attention.
12. When administering a blood transfusion, what is the nurse's priority action if the
patient develops hives and pruritus?
A. Slow the infusion rate
B. Stop the infusion and disconnect the tubing
