NUR 417 CARE OF ADULT 2 – QUESTIONS AND
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1. A 68-year-old patient is admitted with worsening shortness of breath,
bilateral crackles, and pitting edema. Which assessment finding most strongly
supports a diagnosis of left-sided heart failure?
A. Jugular venous distention
B. Pulmonary crackles with orthopnea
C. Hepatomegaly
D. Ascites
Rationale: Left-sided heart failure primarily causes pulmonary congestion,
resulting in crackles, dyspnea, and orthopnea. Jugular venous distention,
hepatomegaly, and ascites are more commonly associated with right-sided heart
failure.
2. A nurse is caring for a patient experiencing an acute exacerbation of
chronic obstructive pulmonary disease (COPD). Which intervention should be
prioritized?
A. Encourage fluid restriction
B. Administer prescribed bronchodilator therapy
C. Place the patient in a flat supine position
D. Delay oxygen administration until arterial blood gases are obtained
Rationale: Bronchodilators rapidly relieve bronchospasm and improve airflow.
Oxygen should not be unnecessarily delayed when hypoxemia is suspected.
3. A patient develops crushing substernal chest pain that radiates to the left
shoulder and jaw. What is the nurse's priority action?
A. Encourage the patient to ambulate
B. Obtain a 12-lead ECG immediately
C. Administer oral fluids
,D. Schedule an outpatient stress test
Rationale: A 12-lead ECG should be obtained within 10 minutes of suspected
myocardial infarction to facilitate rapid diagnosis and treatment.
4. Which assessment finding requires immediate intervention in a patient
receiving intravenous potassium chloride?
A. Infusion site burning and redness
B. Heart rate of 82 beats/minute
C. Blood pressure of 128/76 mmHg
D. Respiratory rate of 18 breaths/minute
Rationale: Potassium chloride is irritating to veins. Burning or redness may
indicate infiltration or phlebitis and requires prompt assessment.
5. A patient with chronic kidney disease has a serum potassium level of 6.5
mEq/L. Which complication is the highest priority?
A. Muscle cramps
B. Cardiac dysrhythmias
C. Dry skin
D. Weight gain
Rationale: Severe hyperkalemia can cause fatal cardiac conduction
abnormalities and requires immediate treatment.
6. A postoperative patient suddenly becomes restless, tachycardic, and
complains of shortness of breath. Which complication should the nurse
suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Urinary retention
D. Constipation
Rationale: Acute dyspnea, tachycardia, and restlessness in a postoperative patient
strongly suggest pulmonary embolism.
, 7. A patient with diabetic ketoacidosis (DKA) is admitted to the emergency
department. Which intervention has the highest priority?
A. Begin intravenous isotonic fluid replacement
B. Restrict oral fluids
C. Administer long-acting insulin first
D. Encourage ambulation
Rationale: Volume replacement is the first priority in DKA to restore perfusion
before insulin therapy effectively corrects hyperglycemia.
8. Which assessment finding is most consistent with hypocalcemia?
A. Positive Chvostek's sign
B. Bradycardia
C. Decreased neuromuscular excitability
D. Muscle flaccidity
Rationale: Hypocalcemia increases neuromuscular excitability, producing
Chvostek's and Trousseau's signs.
9. A patient receiving unfractionated heparin develops bleeding from the
gums. Which medication should the nurse anticipate administering?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Atropine
Rationale: Protamine sulfate is the specific antidote for unfractionated heparin
overdose.
10. A patient with pneumonia suddenly develops confusion and oxygen
saturation decreases to 84% despite oxygen therapy. What should the nurse
do first?
A. Notify dietary services
B. Assess airway and increase oxygen support per protocol
C. Encourage oral intake
D. Document findings and reassess in one hour
Rationale: Airway, breathing, and oxygenation always take priority in an acutely
deteriorating patient.
ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS PLUS RATIONALES | GUARANTEED
PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST| DOWNLOAD
INSTANT PDF
1. A 68-year-old patient is admitted with worsening shortness of breath,
bilateral crackles, and pitting edema. Which assessment finding most strongly
supports a diagnosis of left-sided heart failure?
A. Jugular venous distention
B. Pulmonary crackles with orthopnea
C. Hepatomegaly
D. Ascites
Rationale: Left-sided heart failure primarily causes pulmonary congestion,
resulting in crackles, dyspnea, and orthopnea. Jugular venous distention,
hepatomegaly, and ascites are more commonly associated with right-sided heart
failure.
2. A nurse is caring for a patient experiencing an acute exacerbation of
chronic obstructive pulmonary disease (COPD). Which intervention should be
prioritized?
A. Encourage fluid restriction
B. Administer prescribed bronchodilator therapy
C. Place the patient in a flat supine position
D. Delay oxygen administration until arterial blood gases are obtained
Rationale: Bronchodilators rapidly relieve bronchospasm and improve airflow.
Oxygen should not be unnecessarily delayed when hypoxemia is suspected.
3. A patient develops crushing substernal chest pain that radiates to the left
shoulder and jaw. What is the nurse's priority action?
A. Encourage the patient to ambulate
B. Obtain a 12-lead ECG immediately
C. Administer oral fluids
,D. Schedule an outpatient stress test
Rationale: A 12-lead ECG should be obtained within 10 minutes of suspected
myocardial infarction to facilitate rapid diagnosis and treatment.
4. Which assessment finding requires immediate intervention in a patient
receiving intravenous potassium chloride?
A. Infusion site burning and redness
B. Heart rate of 82 beats/minute
C. Blood pressure of 128/76 mmHg
D. Respiratory rate of 18 breaths/minute
Rationale: Potassium chloride is irritating to veins. Burning or redness may
indicate infiltration or phlebitis and requires prompt assessment.
5. A patient with chronic kidney disease has a serum potassium level of 6.5
mEq/L. Which complication is the highest priority?
A. Muscle cramps
B. Cardiac dysrhythmias
C. Dry skin
D. Weight gain
Rationale: Severe hyperkalemia can cause fatal cardiac conduction
abnormalities and requires immediate treatment.
6. A postoperative patient suddenly becomes restless, tachycardic, and
complains of shortness of breath. Which complication should the nurse
suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Urinary retention
D. Constipation
Rationale: Acute dyspnea, tachycardia, and restlessness in a postoperative patient
strongly suggest pulmonary embolism.
, 7. A patient with diabetic ketoacidosis (DKA) is admitted to the emergency
department. Which intervention has the highest priority?
A. Begin intravenous isotonic fluid replacement
B. Restrict oral fluids
C. Administer long-acting insulin first
D. Encourage ambulation
Rationale: Volume replacement is the first priority in DKA to restore perfusion
before insulin therapy effectively corrects hyperglycemia.
8. Which assessment finding is most consistent with hypocalcemia?
A. Positive Chvostek's sign
B. Bradycardia
C. Decreased neuromuscular excitability
D. Muscle flaccidity
Rationale: Hypocalcemia increases neuromuscular excitability, producing
Chvostek's and Trousseau's signs.
9. A patient receiving unfractionated heparin develops bleeding from the
gums. Which medication should the nurse anticipate administering?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Atropine
Rationale: Protamine sulfate is the specific antidote for unfractionated heparin
overdose.
10. A patient with pneumonia suddenly develops confusion and oxygen
saturation decreases to 84% despite oxygen therapy. What should the nurse
do first?
A. Notify dietary services
B. Assess airway and increase oxygen support per protocol
C. Encourage oral intake
D. Document findings and reassess in one hour
Rationale: Airway, breathing, and oxygenation always take priority in an acutely
deteriorating patient.
