NUR 417 NURSING CARE OF THE
ADULT 2 EXAM 1 REVIEW | 200 LATEST
EXAM QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALES (NEWEST
REVIEW GUIDE)
1. A nurse is caring for a patient with acute decompensated heart failure. Which
assessment finding requires the most immediate intervention?
A. Mild bilateral ankle edema
B. Weight gain of 1 kg over 24 hours
C. Pink, frothy sputum and severe dyspnea
D. Blood pressure of 138/84 mmHg
Answer: C. Pink, frothy sputum and severe dyspnea
Rationale: Pink, frothy sputum with severe dyspnea suggests acute pulmonary
edema, which can rapidly cause life-threatening hypoxemia. Immediate
respiratory support and treatment of pulmonary congestion are priorities.
2. A patient with chronic kidney disease has a serum potassium level of 6.4
mEq/L. Which assessment is the priority?
A. Bowel sounds
B. Cardiac rhythm
C. Skin turgor
D. Peripheral edema
Answer: B. Cardiac rhythm
Rationale: Severe hyperkalemia can cause potentially fatal cardiac
dysrhythmias. Continuous ECG monitoring is a priority while interventions to
lower potassium are initiated.
,3. A patient with cirrhosis develops increasing abdominal distention. Which
complication is the nurse most likely assessing?
A. Ascites
B. Melena
C. Hematemesis
D. Cholecystitis
Answer: A. Ascites
Rationale: Portal hypertension and decreased plasma oncotic pressure
associated with advanced liver disease can cause accumulation of fluid in the
peritoneal cavity, producing ascites.
4. A patient with hypokalemia is receiving IV potassium chloride. Which
nursing action is essential?
A. Administer potassium by IV push.
B. Use an infusion pump for administration.
C. Mix potassium with blood products.
D. Stop cardiac monitoring during administration.
Answer: B. Use an infusion pump for administration.
Rationale: IV potassium must be diluted and administered at a controlled rate
using an infusion pump. IV potassium should never be administered by IV push
because rapid administration can cause fatal cardiac dysrhythmias.
5. A patient with suspected upper gastrointestinal bleeding has hematemesis and
a blood pressure of 88/54 mmHg. What is the nurse's priority?
A. Obtain a dietary history.
B. Establish or maintain large-bore IV access.
C. Administer an oral antacid.
D. Encourage ambulation.
Answer: B. Establish or maintain large-bore IV access.
Rationale: Hypotension with hematemesis suggests significant blood loss and
possible hypovolemic shock. Rapid IV access allows administration of fluids,
blood products, and medications.
,6. A patient with acute kidney injury has oliguria. Which finding should the
nurse report immediately?
A. Potassium 6.2 mEq/L
B. BUN 42 mg/dL
C. Mild fatigue
D. Urine output of 35 mL/hour
Answer: A. Potassium 6.2 mEq/L
Rationale: Severe hyperkalemia is a medical emergency because it can produce
dangerous cardiac conduction abnormalities and dysrhythmias.
7. Which finding is most consistent with fluid volume overload?
A. Flat neck veins
B. Orthostatic hypotension
C. Crackles at the lung bases
D. Dry mucous membranes
Answer: C. Crackles at the lung bases
Rationale: Excess intravascular volume can increase pulmonary hydrostatic
pressure and produce pulmonary congestion manifested by crackles.
8. A patient receiving furosemide should be monitored most closely for which
electrolyte imbalance?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypermagnesemia
Answer: C. Hypokalemia
Rationale: Furosemide is a loop diuretic that increases urinary potassium
excretion. Significant potassium loss can cause muscle weakness and cardiac
dysrhythmias.
, 9. A patient with cirrhosis becomes confused and has asterixis. Which
laboratory abnormality is most likely associated with these findings?
A. Increased ammonia
B. Decreased calcium
C. Increased sodium
D. Decreased glucose
Answer: A. Increased ammonia
Rationale: Hepatic dysfunction reduces the liver's ability to metabolize
ammonia. Accumulation of ammonia contributes to hepatic encephalopathy,
which may manifest as confusion and asterixis.
10. A patient with acute pancreatitis reports severe epigastric pain radiating to
the back. Which intervention is appropriate?
A. Encourage a high-fat meal.
B. Maintain prescribed pancreatic rest/NPO status.
C. Encourage alcohol consumption to stimulate appetite.
D. Place the patient flat after meals.
Answer: B. Maintain prescribed pancreatic rest/NPO status.
Rationale: During acute pancreatitis, reducing pancreatic stimulation may
decrease pancreatic enzyme secretion and support recovery. IV fluids, pain
management, and other supportive measures are also commonly required.
11. Which assessment finding is most concerning in a patient with severe
hyponatremia?
A. Increased appetite
B. Confusion and seizures
C. Warm, dry skin
D. Increased urine concentration
Answer: B. Confusion and seizures
ADULT 2 EXAM 1 REVIEW | 200 LATEST
EXAM QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALES (NEWEST
REVIEW GUIDE)
1. A nurse is caring for a patient with acute decompensated heart failure. Which
assessment finding requires the most immediate intervention?
A. Mild bilateral ankle edema
B. Weight gain of 1 kg over 24 hours
C. Pink, frothy sputum and severe dyspnea
D. Blood pressure of 138/84 mmHg
Answer: C. Pink, frothy sputum and severe dyspnea
Rationale: Pink, frothy sputum with severe dyspnea suggests acute pulmonary
edema, which can rapidly cause life-threatening hypoxemia. Immediate
respiratory support and treatment of pulmonary congestion are priorities.
2. A patient with chronic kidney disease has a serum potassium level of 6.4
mEq/L. Which assessment is the priority?
A. Bowel sounds
B. Cardiac rhythm
C. Skin turgor
D. Peripheral edema
Answer: B. Cardiac rhythm
Rationale: Severe hyperkalemia can cause potentially fatal cardiac
dysrhythmias. Continuous ECG monitoring is a priority while interventions to
lower potassium are initiated.
,3. A patient with cirrhosis develops increasing abdominal distention. Which
complication is the nurse most likely assessing?
A. Ascites
B. Melena
C. Hematemesis
D. Cholecystitis
Answer: A. Ascites
Rationale: Portal hypertension and decreased plasma oncotic pressure
associated with advanced liver disease can cause accumulation of fluid in the
peritoneal cavity, producing ascites.
4. A patient with hypokalemia is receiving IV potassium chloride. Which
nursing action is essential?
A. Administer potassium by IV push.
B. Use an infusion pump for administration.
C. Mix potassium with blood products.
D. Stop cardiac monitoring during administration.
Answer: B. Use an infusion pump for administration.
Rationale: IV potassium must be diluted and administered at a controlled rate
using an infusion pump. IV potassium should never be administered by IV push
because rapid administration can cause fatal cardiac dysrhythmias.
5. A patient with suspected upper gastrointestinal bleeding has hematemesis and
a blood pressure of 88/54 mmHg. What is the nurse's priority?
A. Obtain a dietary history.
B. Establish or maintain large-bore IV access.
C. Administer an oral antacid.
D. Encourage ambulation.
Answer: B. Establish or maintain large-bore IV access.
Rationale: Hypotension with hematemesis suggests significant blood loss and
possible hypovolemic shock. Rapid IV access allows administration of fluids,
blood products, and medications.
,6. A patient with acute kidney injury has oliguria. Which finding should the
nurse report immediately?
A. Potassium 6.2 mEq/L
B. BUN 42 mg/dL
C. Mild fatigue
D. Urine output of 35 mL/hour
Answer: A. Potassium 6.2 mEq/L
Rationale: Severe hyperkalemia is a medical emergency because it can produce
dangerous cardiac conduction abnormalities and dysrhythmias.
7. Which finding is most consistent with fluid volume overload?
A. Flat neck veins
B. Orthostatic hypotension
C. Crackles at the lung bases
D. Dry mucous membranes
Answer: C. Crackles at the lung bases
Rationale: Excess intravascular volume can increase pulmonary hydrostatic
pressure and produce pulmonary congestion manifested by crackles.
8. A patient receiving furosemide should be monitored most closely for which
electrolyte imbalance?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypermagnesemia
Answer: C. Hypokalemia
Rationale: Furosemide is a loop diuretic that increases urinary potassium
excretion. Significant potassium loss can cause muscle weakness and cardiac
dysrhythmias.
, 9. A patient with cirrhosis becomes confused and has asterixis. Which
laboratory abnormality is most likely associated with these findings?
A. Increased ammonia
B. Decreased calcium
C. Increased sodium
D. Decreased glucose
Answer: A. Increased ammonia
Rationale: Hepatic dysfunction reduces the liver's ability to metabolize
ammonia. Accumulation of ammonia contributes to hepatic encephalopathy,
which may manifest as confusion and asterixis.
10. A patient with acute pancreatitis reports severe epigastric pain radiating to
the back. Which intervention is appropriate?
A. Encourage a high-fat meal.
B. Maintain prescribed pancreatic rest/NPO status.
C. Encourage alcohol consumption to stimulate appetite.
D. Place the patient flat after meals.
Answer: B. Maintain prescribed pancreatic rest/NPO status.
Rationale: During acute pancreatitis, reducing pancreatic stimulation may
decrease pancreatic enzyme secretion and support recovery. IV fluids, pain
management, and other supportive measures are also commonly required.
11. Which assessment finding is most concerning in a patient with severe
hyponatremia?
A. Increased appetite
B. Confusion and seizures
C. Warm, dry skin
D. Increased urine concentration
Answer: B. Confusion and seizures
