Maryville NR 324 Adult Health Nursing
Exam 2 With Actual 120 Questions &
Verified Answers,Plus
Rationales/Expert Verified For
Guaranteed Pass Graded A+/
2025/2026 /Latest Update/Instant
Download Pdf
1. A client with COPD is receiving oxygen therapy at 4 L/min via nasal cannula. Which
action should the nurse take?
a. Maintain the oxygen at 4 L/min
b. Increase oxygen to 6 L/min if dyspnea worsens
c. Notify the provider and reduce oxygen to 2 L/min
d. Switch to a non-rebreather mask
Rationale: Clients with COPD rely on hypoxic drive to stimulate breathing. Too much
oxygen can suppress respiration, so the nurse should reduce oxygen to safe levels
(1–2 L/min).
2. A client is admitted with diabetic ketoacidosis (DKA). Which IV solution should the
nurse anticipate administering first?
a. 5% dextrose in 0.45% NS
b. 0.9% NS
c. 0.45% NS
d. Lactated Ringer’s
Rationale: The priority in DKA is fluid resuscitation with isotonic fluids (0.9% NS) to
restore perfusion before correcting electrolytes and glucose.
3. Which finding indicates a positive Trousseau’s sign in a client with hypocalcemia?
a. Facial twitching with tapping of the cheek
b. Carpal spasm with inflation of a blood pressure cuff
c. Muscle weakness in the lower extremities
d. Tremors when hands are extended
, Rationale: Trousseau’s sign is carpal spasm induced by inflation of a BP cuff,
indicating hypocalcemia.
4. A client is admitted with pneumonia. Which assessment finding is most concerning?
a. Fever of 101.4°F
b. Productive cough with yellow sputum
c. Respiratory rate of 32/min with use of accessory muscles
d. Diminished breath sounds in the lower lobes
Rationale: Respiratory distress with tachypnea and accessory muscle use indicates
impending respiratory failure, which is priority.
5. A client with cirrhosis develops ascites. Which nursing intervention is priority?
a. Encourage increased oral fluids
b. Measure abdominal girth daily
c. Restrict sodium intake
d. Place in high Fowler’s position
Rationale: Measuring abdominal girth daily is essential for monitoring fluid
retention and disease progression.
6. A client with heart failure is prescribed furosemide. Which finding indicates the drug
is effective?
a. Weight gain of 2 lbs overnight
b. Decreased crackles in the lungs
c. Increased blood pressure
d. Edema in lower extremities
Rationale: Furosemide is a diuretic that reduces pulmonary congestion, evidenced
by decreased crackles.
7. Which lab result is most concerning for a client taking warfarin?
a. INR 2.2
b. INR 2.5
c. INR 5.0
d. INR 1.8
Rationale: An INR of 5.0 indicates excessive anticoagulation and increased bleeding
risk.
8. A client with a stroke has right-sided hemiplegia. Which intervention is appropriate?
a. Place objects on the client’s right side
b. Position the client flat to promote cerebral circulation
c. Place objects within reach on the left side
d. Encourage fluid intake only when sitting upright
Rationale: Clients with hemiplegia should have items placed on the unaffected side
to encourage independence.
, 9. A client with type 2 diabetes reports dizziness, sweating, and shakiness. Blood
glucose is 52 mg/dL. What is the best nursing action?
a. Administer insulin
b. Give 4 oz of fruit juice
c. Call the provider immediately
d. Give 1 L IV normal saline
Rationale: Hypoglycemia should be treated with a rapid-acting carbohydrate such
as fruit juice.
10. Which assessment finding suggests digoxin toxicity?
a. Blood pressure 150/90
b. Weight gain of 3 lbs
c. Nausea, vomiting, and blurred vision
d. Bounding pulse
Rationale: Classic signs of digoxin toxicity include GI upset and visual disturbances.
11. A client is admitted with suspected myocardial infarction. Which lab test is most
specific for cardiac muscle damage?
a. CK-MB
b. Troponin I
c. Myoglobin
d. BNP
Rationale: Troponin I is the most specific biomarker for myocardial injury and
remains elevated for several days.
12. A client with a tracheostomy becomes suddenly restless and tachypneic. What is the
nurse’s first action?
a. Call the rapid response team
b. Assess airway patency
c. Administer oxygen by face mask
d. Increase IV fluids
Rationale: Restlessness and tachypnea may indicate airway obstruction. The nurse
must check airway patency first.
13. Which client is most at risk for developing hypokalemia?
a. A client receiving spironolactone
b. A client with renal failure
c. A client on continuous NG suction
d. A client taking lisinopril
Rationale: NG suction removes gastric contents rich in potassium, leading to
hypokalemia.
Exam 2 With Actual 120 Questions &
Verified Answers,Plus
Rationales/Expert Verified For
Guaranteed Pass Graded A+/
2025/2026 /Latest Update/Instant
Download Pdf
1. A client with COPD is receiving oxygen therapy at 4 L/min via nasal cannula. Which
action should the nurse take?
a. Maintain the oxygen at 4 L/min
b. Increase oxygen to 6 L/min if dyspnea worsens
c. Notify the provider and reduce oxygen to 2 L/min
d. Switch to a non-rebreather mask
Rationale: Clients with COPD rely on hypoxic drive to stimulate breathing. Too much
oxygen can suppress respiration, so the nurse should reduce oxygen to safe levels
(1–2 L/min).
2. A client is admitted with diabetic ketoacidosis (DKA). Which IV solution should the
nurse anticipate administering first?
a. 5% dextrose in 0.45% NS
b. 0.9% NS
c. 0.45% NS
d. Lactated Ringer’s
Rationale: The priority in DKA is fluid resuscitation with isotonic fluids (0.9% NS) to
restore perfusion before correcting electrolytes and glucose.
3. Which finding indicates a positive Trousseau’s sign in a client with hypocalcemia?
a. Facial twitching with tapping of the cheek
b. Carpal spasm with inflation of a blood pressure cuff
c. Muscle weakness in the lower extremities
d. Tremors when hands are extended
, Rationale: Trousseau’s sign is carpal spasm induced by inflation of a BP cuff,
indicating hypocalcemia.
4. A client is admitted with pneumonia. Which assessment finding is most concerning?
a. Fever of 101.4°F
b. Productive cough with yellow sputum
c. Respiratory rate of 32/min with use of accessory muscles
d. Diminished breath sounds in the lower lobes
Rationale: Respiratory distress with tachypnea and accessory muscle use indicates
impending respiratory failure, which is priority.
5. A client with cirrhosis develops ascites. Which nursing intervention is priority?
a. Encourage increased oral fluids
b. Measure abdominal girth daily
c. Restrict sodium intake
d. Place in high Fowler’s position
Rationale: Measuring abdominal girth daily is essential for monitoring fluid
retention and disease progression.
6. A client with heart failure is prescribed furosemide. Which finding indicates the drug
is effective?
a. Weight gain of 2 lbs overnight
b. Decreased crackles in the lungs
c. Increased blood pressure
d. Edema in lower extremities
Rationale: Furosemide is a diuretic that reduces pulmonary congestion, evidenced
by decreased crackles.
7. Which lab result is most concerning for a client taking warfarin?
a. INR 2.2
b. INR 2.5
c. INR 5.0
d. INR 1.8
Rationale: An INR of 5.0 indicates excessive anticoagulation and increased bleeding
risk.
8. A client with a stroke has right-sided hemiplegia. Which intervention is appropriate?
a. Place objects on the client’s right side
b. Position the client flat to promote cerebral circulation
c. Place objects within reach on the left side
d. Encourage fluid intake only when sitting upright
Rationale: Clients with hemiplegia should have items placed on the unaffected side
to encourage independence.
, 9. A client with type 2 diabetes reports dizziness, sweating, and shakiness. Blood
glucose is 52 mg/dL. What is the best nursing action?
a. Administer insulin
b. Give 4 oz of fruit juice
c. Call the provider immediately
d. Give 1 L IV normal saline
Rationale: Hypoglycemia should be treated with a rapid-acting carbohydrate such
as fruit juice.
10. Which assessment finding suggests digoxin toxicity?
a. Blood pressure 150/90
b. Weight gain of 3 lbs
c. Nausea, vomiting, and blurred vision
d. Bounding pulse
Rationale: Classic signs of digoxin toxicity include GI upset and visual disturbances.
11. A client is admitted with suspected myocardial infarction. Which lab test is most
specific for cardiac muscle damage?
a. CK-MB
b. Troponin I
c. Myoglobin
d. BNP
Rationale: Troponin I is the most specific biomarker for myocardial injury and
remains elevated for several days.
12. A client with a tracheostomy becomes suddenly restless and tachypneic. What is the
nurse’s first action?
a. Call the rapid response team
b. Assess airway patency
c. Administer oxygen by face mask
d. Increase IV fluids
Rationale: Restlessness and tachypnea may indicate airway obstruction. The nurse
must check airway patency first.
13. Which client is most at risk for developing hypokalemia?
a. A client receiving spironolactone
b. A client with renal failure
c. A client on continuous NG suction
d. A client taking lisinopril
Rationale: NG suction removes gastric contents rich in potassium, leading to
hypokalemia.
