NUR 202 ADULT HEALTH II EXAM GUIDE 2026/27
UPDATED EDITION Q&A
1. A 68-year-old client with chronic heart failure presents with
sudden onset of severe dyspnea, pink frothy sputum, and crackles
throughout both lung fields. The nurse should prioritize which
intervention?
A. Administer oxygen at 2 L/min via nasal cannula
B. Place the client in High Fowler's position
C. Administer IV furosemide 40 mg
D. Obtain a 12-lead ECG
Correct Answer: B
Explanation: Placing the client in High Fowler's position is the
priority intervention as it decreases venous return (preload),
reduces pulmonary congestion, and maximizes lung expansion.
While oxygen, diuretics, and ECG are important, positioning
provides immediate relief of respiratory distress in acute
pulmonary edema.
2. A client with deep vein thrombosis (DVT) is receiving heparin
infusion. The nurse notes the PTT is 90 seconds (normal: 25-35
seconds). What is the appropriate nursing action?
A. Continue the infusion as ordered
B. Decrease the infusion rate by 10%
C. Hold the infusion and notify the healthcare provider
D. Increase the infusion rate by 20%
Correct Answer: C
Explanation: The therapeutic PTT range for heparin is 1.5-2.5
, times normal (approximately 40-87.5 seconds). A PTT of 90
seconds indicates supratherapeutic levels and increased bleeding
risk. The infusion should be held and the provider notified
immediately.
3. Which assessment finding in a client with myocardial infarction
requires immediate intervention?
A. ST-segment elevation on ECG
B. Heart rate of 110 bpm
C. S3 heart sound
D. Blood pressure of 90/50 mmHg
Correct Answer: D
Explanation: Hypotension (BP 90/50) in MI indicates cardiogenic
shock or significant hemodynamic compromise, requiring
immediate intervention. While ST elevation confirms MI,
tachycardia and S3 are concerning, hypotension poses the most
immediate threat to organ perfusion.
4. A client with COPD has an arterial blood gas showing pH 7.32,
PaCO2 58 mmHg, PaO2 62 mmHg, HCO3 30 mEq/L. How should
the nurse interpret these results?
A. Uncompensated respiratory alkalosis
B. Partially compensated respiratory acidosis
C. Fully compensated metabolic acidosis
D. Uncompensated metabolic alkalosis
Correct Answer: B
Explanation: The low pH (7.32) and elevated PaCO2 (58) indicate
, respiratory acidosis. The elevated HCO3 (30) shows renal
compensation is occurring but pH remains abnormal, indicating
partial compensation. This is typical in chronic COPD.
5. Which medication should the nurse administer first to a client
experiencing acute asthma exacerbation with severe wheezing
and oxygen saturation of 88%?
A. IV methylprednisolone
B. Albuterol nebulizer treatment
C. Ipratropium bromide nebulizer
D. Oxygen via nasal cannula
Correct Answer: D
Explanation: Oxygen is the priority (ABCs - Airway, Breathing,
Circulation) to correct hypoxemia immediately. While albuterol is
crucial for bronchodilation, correcting life-threatening hypoxia
takes precedence. Oxygen should be administered while preparing
bronchodilators.
6. A client with type 2 diabetes presents with blood glucose of 450
mg/dL, polyuria, polydipsia, and nausea. Ketones are negative in
urine. What condition does the nurse suspect?
A. Diabetic ketoacidosis (DKA)
B. Hyperosmolar hyperglycemic state (HHS)
C. Hypoglycemia
D. Lactic acidosis
Correct Answer: B
Explanation: HHS is characterized by severe hyperglycemia (>600
, mg/dL typically), hyperosmolality, and dehydration without
significant ketosis. The absence of ketones and very high glucose in
a type 2 diabetic points to HHS rather than DKA, which is more
common in type 1 diabetes with positive ketones.
7. Which finding indicates effective treatment of dehydration in an
elderly client?
A. Urine output of 20 mL/hour
B. Specific gravity of 1.028
C. Moist mucous membranes
D. Blood urea nitrogen (BUN) of 35 mg/dL
Correct Answer: C
Explanation: Moist mucous membranes indicate adequate
hydration. Urine output should be 30 mL/hour or more, specific
gravity should be 1.010-1.020 (1.028 indicates concentration), and
BUN should be 10-20 mg/dL (35 is elevated).
8. A client with cirrhosis develops hepatic encephalopathy. Which
intervention should the nurse implement?
A. Increase protein intake to 1.5 g/kg
B. Administer lactulose as prescribed
C. Restrict fluid intake to 1000 mL/day
D. Encourage ambulation every 2 hours
Correct Answer: B
Explanation: Lactulose reduces ammonia absorption in the gut by
acidifying the colon and acting as a cathartic, which is the primary
treatment for hepatic encephalopathy. Protein should be
UPDATED EDITION Q&A
1. A 68-year-old client with chronic heart failure presents with
sudden onset of severe dyspnea, pink frothy sputum, and crackles
throughout both lung fields. The nurse should prioritize which
intervention?
A. Administer oxygen at 2 L/min via nasal cannula
B. Place the client in High Fowler's position
C. Administer IV furosemide 40 mg
D. Obtain a 12-lead ECG
Correct Answer: B
Explanation: Placing the client in High Fowler's position is the
priority intervention as it decreases venous return (preload),
reduces pulmonary congestion, and maximizes lung expansion.
While oxygen, diuretics, and ECG are important, positioning
provides immediate relief of respiratory distress in acute
pulmonary edema.
2. A client with deep vein thrombosis (DVT) is receiving heparin
infusion. The nurse notes the PTT is 90 seconds (normal: 25-35
seconds). What is the appropriate nursing action?
A. Continue the infusion as ordered
B. Decrease the infusion rate by 10%
C. Hold the infusion and notify the healthcare provider
D. Increase the infusion rate by 20%
Correct Answer: C
Explanation: The therapeutic PTT range for heparin is 1.5-2.5
, times normal (approximately 40-87.5 seconds). A PTT of 90
seconds indicates supratherapeutic levels and increased bleeding
risk. The infusion should be held and the provider notified
immediately.
3. Which assessment finding in a client with myocardial infarction
requires immediate intervention?
A. ST-segment elevation on ECG
B. Heart rate of 110 bpm
C. S3 heart sound
D. Blood pressure of 90/50 mmHg
Correct Answer: D
Explanation: Hypotension (BP 90/50) in MI indicates cardiogenic
shock or significant hemodynamic compromise, requiring
immediate intervention. While ST elevation confirms MI,
tachycardia and S3 are concerning, hypotension poses the most
immediate threat to organ perfusion.
4. A client with COPD has an arterial blood gas showing pH 7.32,
PaCO2 58 mmHg, PaO2 62 mmHg, HCO3 30 mEq/L. How should
the nurse interpret these results?
A. Uncompensated respiratory alkalosis
B. Partially compensated respiratory acidosis
C. Fully compensated metabolic acidosis
D. Uncompensated metabolic alkalosis
Correct Answer: B
Explanation: The low pH (7.32) and elevated PaCO2 (58) indicate
, respiratory acidosis. The elevated HCO3 (30) shows renal
compensation is occurring but pH remains abnormal, indicating
partial compensation. This is typical in chronic COPD.
5. Which medication should the nurse administer first to a client
experiencing acute asthma exacerbation with severe wheezing
and oxygen saturation of 88%?
A. IV methylprednisolone
B. Albuterol nebulizer treatment
C. Ipratropium bromide nebulizer
D. Oxygen via nasal cannula
Correct Answer: D
Explanation: Oxygen is the priority (ABCs - Airway, Breathing,
Circulation) to correct hypoxemia immediately. While albuterol is
crucial for bronchodilation, correcting life-threatening hypoxia
takes precedence. Oxygen should be administered while preparing
bronchodilators.
6. A client with type 2 diabetes presents with blood glucose of 450
mg/dL, polyuria, polydipsia, and nausea. Ketones are negative in
urine. What condition does the nurse suspect?
A. Diabetic ketoacidosis (DKA)
B. Hyperosmolar hyperglycemic state (HHS)
C. Hypoglycemia
D. Lactic acidosis
Correct Answer: B
Explanation: HHS is characterized by severe hyperglycemia (>600
, mg/dL typically), hyperosmolality, and dehydration without
significant ketosis. The absence of ketones and very high glucose in
a type 2 diabetic points to HHS rather than DKA, which is more
common in type 1 diabetes with positive ketones.
7. Which finding indicates effective treatment of dehydration in an
elderly client?
A. Urine output of 20 mL/hour
B. Specific gravity of 1.028
C. Moist mucous membranes
D. Blood urea nitrogen (BUN) of 35 mg/dL
Correct Answer: C
Explanation: Moist mucous membranes indicate adequate
hydration. Urine output should be 30 mL/hour or more, specific
gravity should be 1.010-1.020 (1.028 indicates concentration), and
BUN should be 10-20 mg/dL (35 is elevated).
8. A client with cirrhosis develops hepatic encephalopathy. Which
intervention should the nurse implement?
A. Increase protein intake to 1.5 g/kg
B. Administer lactulose as prescribed
C. Restrict fluid intake to 1000 mL/day
D. Encourage ambulation every 2 hours
Correct Answer: B
Explanation: Lactulose reduces ammonia absorption in the gut by
acidifying the colon and acting as a cathartic, which is the primary
treatment for hepatic encephalopathy. Protein should be
