Portage Learning
LANIF · 132 SRUN
★ ★
NURS 231 — Pathophysiology
P
TO TRANSFORM LIVES AND COMMUNITIES BY PROVIDING LEARNING
EST. 1972
OPPORTUNITIES FOR ALL WHO ASPIRE TO THRIVE.
Portage Learning NURS 231 Final Exam
CO M P L E T E Q U E ST I O N S & CO R R E CT D E TA I L E D A N S W E RS
INSTITUTION Portage Learning PROGRAM Bachelor of Science in Nursing
COURSE CODE NURS 231 COURSE TITLE Pathophysiology
ACADEMIC YEAR EXAM TITLE Portage Learning NURS 231 Final
Exam
TOTAL QUESTIONS 100 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ Pathophysiology concepts including respiratory failure, shock, acute coronary syndrome, and
associated complications are all testable content.
▸ Anticoagulation therapy, mechanical ventilation, sepsis, and cardiac emergencies are emphasized.
▸ Correct answers and clinical rationales appear below each question.
▸ All content reflects current evidence-based pathophysiology principles.
, SECTION I — PATHOPHYSIOLOGY: COMPREHENSIVE
Questions 1 – 100
REVIEW
1. A patient has been admitted with a diagnosis of pulmonary embolism and is receiving
heparin infusion. What safety priority does the nurse include in the plan of care?
A. Notify radiology of an impending scan.
B. Ensure adequate staffing for the unit.
C. Monitor the platelet count daily.
D. Teach the client to avoid using dental floss.
CORRECT ANSWER C — Monitor the platelet count daily.
RATIONALE Daily platelet counts are a safety priority in assessing for heparin-induced
thrombocytopenia (HIT), a potential side effect of heparin. While avoiding dental
floss is important during anticoagulation therapy, it is not the priority. Monitoring
for HIT is essential because it can lead to life-threatening thrombosis.
2. A client in ICU who is receiving mechanical ventilation begins to pick at the bedcovers.
Which action will the nurse take next?
A. Request that the family leave to decrease the client's agitation.
B. Assess for adequate oxygenation.
C. Explain that the tube in the client's throat helps with breathing.
D. Increase the sedation.
CORRECT ANSWER B — Assess for adequate oxygenation.
RATIONALE Restlessness, agitation, anxiety, and tachycardia are early symptoms of
hypoxemia. Increasing sedation is not indicated and may mask symptoms such as
hypoxemia or worsening respiratory failure. The nurse must first assess
oxygenation status before intervening.
,3. The nurse is caring for a group of clients with respiratory disorders. For which of these
clients does the nurse plan for immediate intubation?
A. Client who requires suctioning of oral secretions
B. Client with O2 saturation of 90%
C. Client with hypoventilation and decreased breath sounds
D. Client with thick, purulent secretions and crackles
CORRECT ANSWER C — Client with hypoventilation and decreased breath sounds
RATIONALE There is no indication that the client with difficulty handling oral secretions or
who has purulent sputum has hypoxemia or airway obstruction interfering with
swallowing. Intubation may be indicated for the client with an O2 saturation of
less than 90% and other symptoms of hypoxemia or hypercarbia. Hypoventilation
with decreased breath sounds indicates respiratory failure requiring immediate
intubation.
4. The nurse is assessing a client who is receiving mechanical ventilation with positive end-
expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension
pneumothorax?
A. Chest asymmetry and jugular vein distention are present.
B. The client has bloody sputum and wheezes.
C. The left lung field is dull to percussion with crackles present on auscultation.
D. The left chest caves in on inspiration and "puffs out" on expiration.
CORRECT ANSWER A — Chest asymmetry and jugular vein distention are present.
RATIONALE Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation
toward the unaffected side, dyspnea, absent breath sounds, JVD, and cyanosis. If
not promptly detected and treated, tension pneumothorax is quickly fatal.
, 5. The charge nurse in the intensive care unit is overseeing care for a group of clients. The
nurse is especially vigilant in collaboration with the primary nurse and interprofessional
team in assessing for ARDS in which of these clients?
A. Client with acute kidney failure
B. Client with aspiration pneumonia
C. Client with atrial fibrillation
D. Client with diabetic ketoacidosis
CORRECT ANSWER B — Client with aspiration pneumonia
RATIONALE Acute Respiratory Distress Syndrome is characterized by widespread
inflammation in the lungs. Aspiration of acidic gastric contents promotes
inflammation and is a risk for ARDS. Clients with DKA may develop metabolic
acidosis but do not typically develop ARDS.
6. The nurse is providing education about the management of respiratory failure to the
family of a client who is receiving mechanical ventilation. Which statement reflects the
MOST appropriate information that the nurse will communicate?
A. "Paralytics and sedatives help decrease the demand for oxygen."
B. "Sedation is needed so your loved one does not rip the breathing tube out."
C. "Suctioning is important to remove organisms from the lower airway."
D. "We are encouraging oral and IV fluids to keep your loved one hydrated."
CORRECT ANSWER A — "Paralytics and sedatives help decrease the demand for oxygen."
RATIONALE Sedation is needed more for its effects on oxygenation than to prevent the client
from ripping out the endotracheal tube. Suctioning is performed to remove upper
airway secretions and maintain airway patency. Clients receiving mechanical
ventilation typically receive hydration by enteral tube or parenteral route.
LANIF · 132 SRUN
★ ★
NURS 231 — Pathophysiology
P
TO TRANSFORM LIVES AND COMMUNITIES BY PROVIDING LEARNING
EST. 1972
OPPORTUNITIES FOR ALL WHO ASPIRE TO THRIVE.
Portage Learning NURS 231 Final Exam
CO M P L E T E Q U E ST I O N S & CO R R E CT D E TA I L E D A N S W E RS
INSTITUTION Portage Learning PROGRAM Bachelor of Science in Nursing
COURSE CODE NURS 231 COURSE TITLE Pathophysiology
ACADEMIC YEAR EXAM TITLE Portage Learning NURS 231 Final
Exam
TOTAL QUESTIONS 100 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ Pathophysiology concepts including respiratory failure, shock, acute coronary syndrome, and
associated complications are all testable content.
▸ Anticoagulation therapy, mechanical ventilation, sepsis, and cardiac emergencies are emphasized.
▸ Correct answers and clinical rationales appear below each question.
▸ All content reflects current evidence-based pathophysiology principles.
, SECTION I — PATHOPHYSIOLOGY: COMPREHENSIVE
Questions 1 – 100
REVIEW
1. A patient has been admitted with a diagnosis of pulmonary embolism and is receiving
heparin infusion. What safety priority does the nurse include in the plan of care?
A. Notify radiology of an impending scan.
B. Ensure adequate staffing for the unit.
C. Monitor the platelet count daily.
D. Teach the client to avoid using dental floss.
CORRECT ANSWER C — Monitor the platelet count daily.
RATIONALE Daily platelet counts are a safety priority in assessing for heparin-induced
thrombocytopenia (HIT), a potential side effect of heparin. While avoiding dental
floss is important during anticoagulation therapy, it is not the priority. Monitoring
for HIT is essential because it can lead to life-threatening thrombosis.
2. A client in ICU who is receiving mechanical ventilation begins to pick at the bedcovers.
Which action will the nurse take next?
A. Request that the family leave to decrease the client's agitation.
B. Assess for adequate oxygenation.
C. Explain that the tube in the client's throat helps with breathing.
D. Increase the sedation.
CORRECT ANSWER B — Assess for adequate oxygenation.
RATIONALE Restlessness, agitation, anxiety, and tachycardia are early symptoms of
hypoxemia. Increasing sedation is not indicated and may mask symptoms such as
hypoxemia or worsening respiratory failure. The nurse must first assess
oxygenation status before intervening.
,3. The nurse is caring for a group of clients with respiratory disorders. For which of these
clients does the nurse plan for immediate intubation?
A. Client who requires suctioning of oral secretions
B. Client with O2 saturation of 90%
C. Client with hypoventilation and decreased breath sounds
D. Client with thick, purulent secretions and crackles
CORRECT ANSWER C — Client with hypoventilation and decreased breath sounds
RATIONALE There is no indication that the client with difficulty handling oral secretions or
who has purulent sputum has hypoxemia or airway obstruction interfering with
swallowing. Intubation may be indicated for the client with an O2 saturation of
less than 90% and other symptoms of hypoxemia or hypercarbia. Hypoventilation
with decreased breath sounds indicates respiratory failure requiring immediate
intubation.
4. The nurse is assessing a client who is receiving mechanical ventilation with positive end-
expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension
pneumothorax?
A. Chest asymmetry and jugular vein distention are present.
B. The client has bloody sputum and wheezes.
C. The left lung field is dull to percussion with crackles present on auscultation.
D. The left chest caves in on inspiration and "puffs out" on expiration.
CORRECT ANSWER A — Chest asymmetry and jugular vein distention are present.
RATIONALE Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation
toward the unaffected side, dyspnea, absent breath sounds, JVD, and cyanosis. If
not promptly detected and treated, tension pneumothorax is quickly fatal.
, 5. The charge nurse in the intensive care unit is overseeing care for a group of clients. The
nurse is especially vigilant in collaboration with the primary nurse and interprofessional
team in assessing for ARDS in which of these clients?
A. Client with acute kidney failure
B. Client with aspiration pneumonia
C. Client with atrial fibrillation
D. Client with diabetic ketoacidosis
CORRECT ANSWER B — Client with aspiration pneumonia
RATIONALE Acute Respiratory Distress Syndrome is characterized by widespread
inflammation in the lungs. Aspiration of acidic gastric contents promotes
inflammation and is a risk for ARDS. Clients with DKA may develop metabolic
acidosis but do not typically develop ARDS.
6. The nurse is providing education about the management of respiratory failure to the
family of a client who is receiving mechanical ventilation. Which statement reflects the
MOST appropriate information that the nurse will communicate?
A. "Paralytics and sedatives help decrease the demand for oxygen."
B. "Sedation is needed so your loved one does not rip the breathing tube out."
C. "Suctioning is important to remove organisms from the lower airway."
D. "We are encouraging oral and IV fluids to keep your loved one hydrated."
CORRECT ANSWER A — "Paralytics and sedatives help decrease the demand for oxygen."
RATIONALE Sedation is needed more for its effects on oxygenation than to prevent the client
from ripping out the endotracheal tube. Suctioning is performed to remove upper
airway secretions and maintain airway patency. Clients receiving mechanical
ventilation typically receive hydration by enteral tube or parenteral route.
