NUR2571/NUR 2571 Exam 3 V3 |
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is reviewing the laboratory results of a client with a potassium level of 3.2 mEq/L.
Which assessment finding is most consistent with this result?
A. Tall, peaked T-waves on ECG
B. Abdominal cramping and diarrhea
C. Hyperactive deep tendon reflexes
D. Muscle weakness and shallow respirations
Correct Answer: D
Expert Explanation: A potassium level of 3.2 mEq/L indicates hypokalemia, which often
presents with muscle weakness and diminished deep tendon reflexes. Shallow respirations
occur because the respiratory muscles become weak, potentially leading to respiratory
arrest. The nurse should prioritize assessing the client’s airway and breathing while
preparing for potassium replacement.
2. Which clinical manifestation should the nurse expect in a client experiencing
hypocalcemia?
A. Bone pain and kidney stones
,B. Constipation and lethargy
C. Shortened QT interval
D. Positive Trousseau’s sign
Correct Answer: D
Expert Explanation: Hypocalcemia increases neuromuscular excitability, which is
evidenced by a positive Trousseau’s or Chvostek’s sign. A Trousseau’s sign is observed
when a blood pressure cuff is inflated and the hand experiences a carpal spasm. The nurse
must monitor the client for laryngospasm and seizures as these are life-threatening
complications of low calcium.
3. A client’s arterial blood gas (ABG) results are pH 7.31, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: B
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated
above 45 mmHg, which points to a respiratory cause. Because the bicarbonate (HCO3) is
within the normal range of 22-26 mEq/L, the condition is uncompensated respiratory
, acidosis. This condition often results from hypoventilation or impaired gas exchange in the
lungs.
4. A nurse is caring for a post-operative client who develops a surgical wound evisceration.
What is the priority nursing action?
A. Cover the wound with sterile towels soaked in normal saline
B. Push the protruding organs back into the abdomen
C. Apply a dry sterile dressing to the wound
D. Place the client in a high-Fowler’s position
Correct Answer: A
Expert Explanation: Surgical evisceration is a medical emergency where internal organs
protrude through an incision. The nurse must cover the exposed tissue with sterile, saline-
soaked dressings to keep the organs moist and prevent infection. It is critical to notify the
surgeon immediately and prepare the client for emergency surgery while keeping them in a
low-Fowler’s position with knees bent.
5. The nurse is preparing to administer Digoxin to a client with heart failure. Which
assessment finding would require the nurse to hold the medication?
A. Blood pressure of 110/70 mmHg
B. Apical heart rate of 52 beats per minute
C. Respiratory rate of 18 breaths per minute
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is reviewing the laboratory results of a client with a potassium level of 3.2 mEq/L.
Which assessment finding is most consistent with this result?
A. Tall, peaked T-waves on ECG
B. Abdominal cramping and diarrhea
C. Hyperactive deep tendon reflexes
D. Muscle weakness and shallow respirations
Correct Answer: D
Expert Explanation: A potassium level of 3.2 mEq/L indicates hypokalemia, which often
presents with muscle weakness and diminished deep tendon reflexes. Shallow respirations
occur because the respiratory muscles become weak, potentially leading to respiratory
arrest. The nurse should prioritize assessing the client’s airway and breathing while
preparing for potassium replacement.
2. Which clinical manifestation should the nurse expect in a client experiencing
hypocalcemia?
A. Bone pain and kidney stones
,B. Constipation and lethargy
C. Shortened QT interval
D. Positive Trousseau’s sign
Correct Answer: D
Expert Explanation: Hypocalcemia increases neuromuscular excitability, which is
evidenced by a positive Trousseau’s or Chvostek’s sign. A Trousseau’s sign is observed
when a blood pressure cuff is inflated and the hand experiences a carpal spasm. The nurse
must monitor the client for laryngospasm and seizures as these are life-threatening
complications of low calcium.
3. A client’s arterial blood gas (ABG) results are pH 7.31, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: B
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated
above 45 mmHg, which points to a respiratory cause. Because the bicarbonate (HCO3) is
within the normal range of 22-26 mEq/L, the condition is uncompensated respiratory
, acidosis. This condition often results from hypoventilation or impaired gas exchange in the
lungs.
4. A nurse is caring for a post-operative client who develops a surgical wound evisceration.
What is the priority nursing action?
A. Cover the wound with sterile towels soaked in normal saline
B. Push the protruding organs back into the abdomen
C. Apply a dry sterile dressing to the wound
D. Place the client in a high-Fowler’s position
Correct Answer: A
Expert Explanation: Surgical evisceration is a medical emergency where internal organs
protrude through an incision. The nurse must cover the exposed tissue with sterile, saline-
soaked dressings to keep the organs moist and prevent infection. It is critical to notify the
surgeon immediately and prepare the client for emergency surgery while keeping them in a
low-Fowler’s position with knees bent.
5. The nurse is preparing to administer Digoxin to a client with heart failure. Which
assessment finding would require the nurse to hold the medication?
A. Blood pressure of 110/70 mmHg
B. Apical heart rate of 52 beats per minute
C. Respiratory rate of 18 breaths per minute
