NUR 215 Exam 2 2026/2027 | 300 Practice Questions, Correct Answers
& Detailed Rationales | Nursing Exam Preparation
Question 1
A nurse is preparing to administer IV push furosemide to a client with
acute heart failure. Which assessment finding requires immediate
nursing action prior to drug administration?
A. Serum potassium level of 2.8 mEq/L
B. Blood pressure of 128/78 mmHg
C. Mild 1 + pitting edema in lower extremities
D. Urine output of 40 mL/hr over the past 4 hours
Correct Answer: A. Serum potassium level of 2.8 mEq/L
Detailed Rationale: Furosemide is a loop diuretic that causes significant
renal excretion of potassium. Administering it to a client with severe
hypokalemia (< 3.5 mEq/L) significantly increases the risk of life-
threatening cardiac dysrhythmias. The nurse must withhold the dose
and notify the provider.
Question 2
A nurse is monitoring an adult client who is receiving a continuous
intravenous infusion of 0.9% Normal Saline. The client suddenly reports
acute shortness of breath and exhibits jugular venous distension and
bilateral crackles. Which complication has occurred?
A. Air embolism
B. Circulatory overload (hypervolemia)
C. Catheter embolism
,D. Allergic reaction to normal saline
Correct Answer: B. Circulatory overload (hypervolemia)
Detailed Rationale: Circulatory overload occurs when IV fluid is infused
too rapidly or in excessive volume, expanding intravascular volume
beyond cardiac capacity. Symptoms include dyspnea, tachypnea,
elevated blood pressure, jugular venous distension (JVD), and
pulmonary crackles.
Question 3
A nurse is preparing to perform tracheostomy care for a client with a
non-disposable inner cannula. Which step is correct when cleaning the
inner cannula?
A. Soak and scrub the inner cannula using full-strength concentrated
bleach.
B. Use a small sterile brush with sterile normal saline or half-strength
hydrogen peroxide to clean the cannula, then rinse with sterile saline.
C. Wash the cannula in hot tap water and dry with a paper towel.
D. Submerge the inner cannula in alcohol for 30 minutes before
inserting.
Correct Answer: B. Use a small sterile brush with sterile normal saline
or half-strength hydrogen peroxide to clean the cannula, then rinse with
sterile saline.
Detailed Rationale: Standard tracheostomy care involves cleaning the
non-disposable inner cannula using sterile technique with half-strength
hydrogen peroxide (or sterile normal saline) and a sterile pipe
,cleaner/brush, followed by a thorough rinse with sterile normal saline
to prevent tissue irritation.
Question 4
A nurse is evaluating an arterial blood gas result for a client with severe
chronic obstructive pulmonary disease (COPD): pH = 7.32, PaCO2 =
58 mmHg, HCO− 3 = 30 mEq/L. How should the nurse interpret this
result?
A. Uncompensated metabolic acidosis
B. Partially compensated respiratory acidosis
C. Fully compensated metabolic alkalosis
D. Uncompensated respiratory alkalosis
Correct Answer: B. Partially compensated respiratory acidosis
Detailed Rationale:
pH = 7.32 (< 7.35, acidic).
PaCO2 = 58 mmHg (> 45 mmHg, acidic/respiratory origin).
HCO−
3 = 30 mEq/L (> 26 mEq/L, basic/kidneys compensating).
Because all three parameters are abnormal and the pH remains slightly
outside the normal range (7.35--7.45), this represents partially
compensated respiratory acidosis.
Question 5
A nurse is assessing a client's central venous catheter site and notices
redness, warmth, induration, and purulent drainage at the insertion
site. Which action should the nurse take first?
, A. Apply a warm heating pad over the site for 1 hour.
B. Flush the catheter with 20 mL of sterile water.
C. Notify the provider, obtain blood cultures, and prepare to discontinue
the line per order.
D. Increase the IV infusion rate.
Correct Answer: C. Notify the provider, obtain blood cultures, and
prepare to discontinue the line per order.
Detailed Rationale: Purulent drainage, warmth, and erythema at a
central venous access site indicate a localized infection or central line-
associated bloodstream infection (CLABSI). Priority actions include
notifying the provider, obtaining prescribed peripheral and line blood
cultures, and removing the line with tip culture if ordered.
Question 6
A nurse is providing discharge education to a client with a newly placed
permanent cardiac pacemaker. Which instruction should the nurse
emphasize?
A. "You may freely undergo high-magnetic field MRI scans without
restriction."
B. "Avoid lifting the arm on the pacemaker side above shoulder level for
the first few weeks."
C. "Cell phones should be held directly over the pacemaker site during
calls."
D. "Continuous chest pain and persistent hiccups are normal expected
findings."
& Detailed Rationales | Nursing Exam Preparation
Question 1
A nurse is preparing to administer IV push furosemide to a client with
acute heart failure. Which assessment finding requires immediate
nursing action prior to drug administration?
A. Serum potassium level of 2.8 mEq/L
B. Blood pressure of 128/78 mmHg
C. Mild 1 + pitting edema in lower extremities
D. Urine output of 40 mL/hr over the past 4 hours
Correct Answer: A. Serum potassium level of 2.8 mEq/L
Detailed Rationale: Furosemide is a loop diuretic that causes significant
renal excretion of potassium. Administering it to a client with severe
hypokalemia (< 3.5 mEq/L) significantly increases the risk of life-
threatening cardiac dysrhythmias. The nurse must withhold the dose
and notify the provider.
Question 2
A nurse is monitoring an adult client who is receiving a continuous
intravenous infusion of 0.9% Normal Saline. The client suddenly reports
acute shortness of breath and exhibits jugular venous distension and
bilateral crackles. Which complication has occurred?
A. Air embolism
B. Circulatory overload (hypervolemia)
C. Catheter embolism
,D. Allergic reaction to normal saline
Correct Answer: B. Circulatory overload (hypervolemia)
Detailed Rationale: Circulatory overload occurs when IV fluid is infused
too rapidly or in excessive volume, expanding intravascular volume
beyond cardiac capacity. Symptoms include dyspnea, tachypnea,
elevated blood pressure, jugular venous distension (JVD), and
pulmonary crackles.
Question 3
A nurse is preparing to perform tracheostomy care for a client with a
non-disposable inner cannula. Which step is correct when cleaning the
inner cannula?
A. Soak and scrub the inner cannula using full-strength concentrated
bleach.
B. Use a small sterile brush with sterile normal saline or half-strength
hydrogen peroxide to clean the cannula, then rinse with sterile saline.
C. Wash the cannula in hot tap water and dry with a paper towel.
D. Submerge the inner cannula in alcohol for 30 minutes before
inserting.
Correct Answer: B. Use a small sterile brush with sterile normal saline
or half-strength hydrogen peroxide to clean the cannula, then rinse with
sterile saline.
Detailed Rationale: Standard tracheostomy care involves cleaning the
non-disposable inner cannula using sterile technique with half-strength
hydrogen peroxide (or sterile normal saline) and a sterile pipe
,cleaner/brush, followed by a thorough rinse with sterile normal saline
to prevent tissue irritation.
Question 4
A nurse is evaluating an arterial blood gas result for a client with severe
chronic obstructive pulmonary disease (COPD): pH = 7.32, PaCO2 =
58 mmHg, HCO− 3 = 30 mEq/L. How should the nurse interpret this
result?
A. Uncompensated metabolic acidosis
B. Partially compensated respiratory acidosis
C. Fully compensated metabolic alkalosis
D. Uncompensated respiratory alkalosis
Correct Answer: B. Partially compensated respiratory acidosis
Detailed Rationale:
pH = 7.32 (< 7.35, acidic).
PaCO2 = 58 mmHg (> 45 mmHg, acidic/respiratory origin).
HCO−
3 = 30 mEq/L (> 26 mEq/L, basic/kidneys compensating).
Because all three parameters are abnormal and the pH remains slightly
outside the normal range (7.35--7.45), this represents partially
compensated respiratory acidosis.
Question 5
A nurse is assessing a client's central venous catheter site and notices
redness, warmth, induration, and purulent drainage at the insertion
site. Which action should the nurse take first?
, A. Apply a warm heating pad over the site for 1 hour.
B. Flush the catheter with 20 mL of sterile water.
C. Notify the provider, obtain blood cultures, and prepare to discontinue
the line per order.
D. Increase the IV infusion rate.
Correct Answer: C. Notify the provider, obtain blood cultures, and
prepare to discontinue the line per order.
Detailed Rationale: Purulent drainage, warmth, and erythema at a
central venous access site indicate a localized infection or central line-
associated bloodstream infection (CLABSI). Priority actions include
notifying the provider, obtaining prescribed peripheral and line blood
cultures, and removing the line with tip culture if ordered.
Question 6
A nurse is providing discharge education to a client with a newly placed
permanent cardiac pacemaker. Which instruction should the nurse
emphasize?
A. "You may freely undergo high-magnetic field MRI scans without
restriction."
B. "Avoid lifting the arm on the pacemaker side above shoulder level for
the first few weeks."
C. "Cell phones should be held directly over the pacemaker site during
calls."
D. "Continuous chest pain and persistent hiccups are normal expected
findings."
