NUR 417 Exam 2 V2 | NUR 417 Nursing Care of the
Adult II | Actual Q&A with Rationale (NUR417
Exam 2) | Concordia
1. A patient is admitted with suspected right-sided heart failure. Which clinical
manifestations should the nurse expect to find? (Select All That Apply)
A. Jugular venous distention (JVD)
B. Dependent peripheral edema
C. Pulmonary crackles and wheezing
D. Hepatomegaly and splenomegaly
E. Ascites and abdominal girth increase
Correct Answer: A, B, D, E
Explanation: Right-sided heart failure results in blood backing up into the systemic venous
circulation, causing JVD, peripheral edema, and organ congestion like hepatomegaly.
Pulmonary crackles are characteristic of left-sided heart failure, where blood backs up into
the lungs. Assessing for weight gain and abdominal girth is critical in monitoring the
progression of right-sided failure.
2. A nurse is caring for a patient on a mechanical ventilator when the high-pressure alarm
sounds. Which action should the nurse take first?
A. Assess the patient’s oxygen saturation
,B. Check the tubing for kinks or obstruction
C. Suction the patient’s airway for secretions
D. Manually ventilate the patient with a bag-valve-mask
Correct Answer: A
Explanation: The primary priority in nursing is always the assessment of the patient’s
physiological status before addressing the equipment. While kinks or secretions are
common causes of high-pressure alarms, the nurse must first ensure the patient is not in
respiratory distress. After assessing the patient, the nurse can then troubleshoot the
machine or suction as needed.
3. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L. Which
rhythm change is the nurse most likely to observe on the EKG monitor?
A. Prominent U waves
B. ST-segment depression
C. Shortened PR interval
D. Tall, peaked T waves
Correct Answer: D
Explanation: Hyperkalemia, defined as potassium levels above 5.0 mEq/L, causes specific
electrophysiological changes, most notably peaked T waves. If left untreated, this can
,progress to a widened QRS complex and eventually ventricular fibrillation or asystole. In
contrast, U waves and ST depression are typically associated with hypokalemia.
4. Which medical diagnosis is categorized as a pre-renal cause of Acute Kidney Injury?
A. Acute tubular necrosis (ATN)
B. Benign prostatic hyperplasia (BPH)
C. Hypovolemic shock
D. Nephrotoxic drug exposure
Correct Answer: C
Explanation: Pre-renal AKI is caused by factors that reduce systemic circulation, causing a
decrease in renal blood flow. Hypovolemic shock leads to decreased perfusion to the
kidneys, triggering a drop in GFR. ATN and nephrotoxins are intra-renal causes, while BPH
is a post-renal cause due to obstruction.
5. A patient in the ICU is being treated for Septic Shock. Which findings indicate the patient is
in the hyperdynamic (warm) phase? (Select All That Apply)
A. Tachycardia
B. Cool, clammy skin
C. Increased cardiac output
D. Flushed, warm skin
E. Decreased urine output
, Correct Answer: A, C, D
Explanation: The early or hyperdynamic phase of septic shock is characterized by high
cardiac output and systemic vasodilation, resulting in warm, flushed skin. Patients are
typically tachycardic as a compensatory mechanism to maintain tissue perfusion despite
falling systemic vascular resistance. Cool, clammy skin and low cardiac output are features
of the late, cold phase of shock.
6. A nurse is monitoring a patient post-permanent pacemaker insertion. Which EKG finding
indicates a failure to sense?
A. Pacer spikes are present but not followed by a QRS complex
B. The PR interval is prolonged beyond 0.20 seconds
C. The patient’s heart rate is 50 bpm with no pacer spikes
D. Pacer spikes occur within the patient’s own QRS complex
Correct Answer: D
Explanation: Failure to sense occurs when the pacemaker does not recognize the patient’s
intrinsic electrical activity and fires at inappropriate times. This is evidenced by pacer
spikes appearing during the patient’s own beats, such as during the QRS or T wave. Failure
to capture is when a spike is not followed by a contraction, and failure to pace is when the
heart rate drops below the set limit without a spike.
Adult II | Actual Q&A with Rationale (NUR417
Exam 2) | Concordia
1. A patient is admitted with suspected right-sided heart failure. Which clinical
manifestations should the nurse expect to find? (Select All That Apply)
A. Jugular venous distention (JVD)
B. Dependent peripheral edema
C. Pulmonary crackles and wheezing
D. Hepatomegaly and splenomegaly
E. Ascites and abdominal girth increase
Correct Answer: A, B, D, E
Explanation: Right-sided heart failure results in blood backing up into the systemic venous
circulation, causing JVD, peripheral edema, and organ congestion like hepatomegaly.
Pulmonary crackles are characteristic of left-sided heart failure, where blood backs up into
the lungs. Assessing for weight gain and abdominal girth is critical in monitoring the
progression of right-sided failure.
2. A nurse is caring for a patient on a mechanical ventilator when the high-pressure alarm
sounds. Which action should the nurse take first?
A. Assess the patient’s oxygen saturation
,B. Check the tubing for kinks or obstruction
C. Suction the patient’s airway for secretions
D. Manually ventilate the patient with a bag-valve-mask
Correct Answer: A
Explanation: The primary priority in nursing is always the assessment of the patient’s
physiological status before addressing the equipment. While kinks or secretions are
common causes of high-pressure alarms, the nurse must first ensure the patient is not in
respiratory distress. After assessing the patient, the nurse can then troubleshoot the
machine or suction as needed.
3. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L. Which
rhythm change is the nurse most likely to observe on the EKG monitor?
A. Prominent U waves
B. ST-segment depression
C. Shortened PR interval
D. Tall, peaked T waves
Correct Answer: D
Explanation: Hyperkalemia, defined as potassium levels above 5.0 mEq/L, causes specific
electrophysiological changes, most notably peaked T waves. If left untreated, this can
,progress to a widened QRS complex and eventually ventricular fibrillation or asystole. In
contrast, U waves and ST depression are typically associated with hypokalemia.
4. Which medical diagnosis is categorized as a pre-renal cause of Acute Kidney Injury?
A. Acute tubular necrosis (ATN)
B. Benign prostatic hyperplasia (BPH)
C. Hypovolemic shock
D. Nephrotoxic drug exposure
Correct Answer: C
Explanation: Pre-renal AKI is caused by factors that reduce systemic circulation, causing a
decrease in renal blood flow. Hypovolemic shock leads to decreased perfusion to the
kidneys, triggering a drop in GFR. ATN and nephrotoxins are intra-renal causes, while BPH
is a post-renal cause due to obstruction.
5. A patient in the ICU is being treated for Septic Shock. Which findings indicate the patient is
in the hyperdynamic (warm) phase? (Select All That Apply)
A. Tachycardia
B. Cool, clammy skin
C. Increased cardiac output
D. Flushed, warm skin
E. Decreased urine output
, Correct Answer: A, C, D
Explanation: The early or hyperdynamic phase of septic shock is characterized by high
cardiac output and systemic vasodilation, resulting in warm, flushed skin. Patients are
typically tachycardic as a compensatory mechanism to maintain tissue perfusion despite
falling systemic vascular resistance. Cool, clammy skin and low cardiac output are features
of the late, cold phase of shock.
6. A nurse is monitoring a patient post-permanent pacemaker insertion. Which EKG finding
indicates a failure to sense?
A. Pacer spikes are present but not followed by a QRS complex
B. The PR interval is prolonged beyond 0.20 seconds
C. The patient’s heart rate is 50 bpm with no pacer spikes
D. Pacer spikes occur within the patient’s own QRS complex
Correct Answer: D
Explanation: Failure to sense occurs when the pacemaker does not recognize the patient’s
intrinsic electrical activity and fires at inappropriate times. This is evidenced by pacer
spikes appearing during the patient’s own beats, such as during the QRS or T wave. Failure
to capture is when a spike is not followed by a contraction, and failure to pace is when the
heart rate drops below the set limit without a spike.
