NUR 3300 Final Exam V1 | NUR 3300
Nursing Practice II | Q&A with Rationale
(NUR3300 Final Exam) | William Paterson
University
1. A patient is admitted with a serum potassium level of 2.8 mEq/L. Which assessment finding
should the nurse prioritize?
A. Increased muscle strength
B. Cardiac dysrhythmias and U-waves
C. Hyperactive bowel sounds
D. Positive Chvostek’s sign
Answer: B
Rationale: Hypokalemia significantly affects cardiac electrical conduction, potentially
leading to lethal arrhythmias. The presence of U-waves on an ECG is a classic indicator of
low potassium levels. The nurse must monitor the patient’s telemetry closely to prevent
cardiac arrest.
2. Which nursing intervention is most effective in preventing postoperative pulmonary
complications such as atelectasis?
A. Restricting fluids to prevent pulmonary edema
B. Teaching the patient to use an incentive spirometer 10 times per hour while awake
,C. Administering cough suppressants every 4 hours
D. Keeping the patient in a supine position for the first 48 hours
Answer: B
Rationale: Incentive spirometry encourages deep breathing and expands the alveoli, which
is crucial for preventing lung collapse after surgery. Regular use helps clear secretions and
improves oxygenation in the early recovery phase. This intervention is a standard
component of postoperative pulmonary hygiene protocols.
3. A patient with Type 1 Diabetes Mellitus presents with deep, rapid respirations and a fruity
breath odor. The nurse should anticipate which laboratory result?
A. Blood glucose of 60 mg/dL
B. Serum bicarbonate of 28 mEq/L
C. Arterial pH of 7.25
D. Negative urine ketones
Answer: C
Rationale: These symptoms are characteristic of Diabetic Ketoacidosis (DKA), which is a
metabolic acidosis state. An arterial pH below 7.35 confirms the presence of acidosis
caused by the accumulation of ketone bodies. Kussmaul respirations are the body’s
compensatory mechanism to blow off excess CO2.
, 4. The nurse is caring for a patient on the second postoperative day. Which finding suggests
the development of a deep vein thrombosis (DVT)?
A. Bilateral pitting edema in the ankles
B. Unilateral calf warmth and tenderness
C. Pale, cool skin on the affected extremity
D. Diminished pedal pulses in both feet
Answer: B
Rationale: DVT typically presents as unilateral swelling, redness, and localized warmth in
the lower extremity. While bilateral edema is often related to heart failure, unilateral
symptoms are a red flag for venous thrombus. Immediate notification of the provider is
required to prevent pulmonary embolism.
5. When administering Albuterol to a patient with an acute asthma attack, which side effect
should the nurse monitor for?
A. Bradycardia
B. Tachycardia and tremors
C. Lethargy and sleepiness
D. Hypoglycemia
Answer: B
Nursing Practice II | Q&A with Rationale
(NUR3300 Final Exam) | William Paterson
University
1. A patient is admitted with a serum potassium level of 2.8 mEq/L. Which assessment finding
should the nurse prioritize?
A. Increased muscle strength
B. Cardiac dysrhythmias and U-waves
C. Hyperactive bowel sounds
D. Positive Chvostek’s sign
Answer: B
Rationale: Hypokalemia significantly affects cardiac electrical conduction, potentially
leading to lethal arrhythmias. The presence of U-waves on an ECG is a classic indicator of
low potassium levels. The nurse must monitor the patient’s telemetry closely to prevent
cardiac arrest.
2. Which nursing intervention is most effective in preventing postoperative pulmonary
complications such as atelectasis?
A. Restricting fluids to prevent pulmonary edema
B. Teaching the patient to use an incentive spirometer 10 times per hour while awake
,C. Administering cough suppressants every 4 hours
D. Keeping the patient in a supine position for the first 48 hours
Answer: B
Rationale: Incentive spirometry encourages deep breathing and expands the alveoli, which
is crucial for preventing lung collapse after surgery. Regular use helps clear secretions and
improves oxygenation in the early recovery phase. This intervention is a standard
component of postoperative pulmonary hygiene protocols.
3. A patient with Type 1 Diabetes Mellitus presents with deep, rapid respirations and a fruity
breath odor. The nurse should anticipate which laboratory result?
A. Blood glucose of 60 mg/dL
B. Serum bicarbonate of 28 mEq/L
C. Arterial pH of 7.25
D. Negative urine ketones
Answer: C
Rationale: These symptoms are characteristic of Diabetic Ketoacidosis (DKA), which is a
metabolic acidosis state. An arterial pH below 7.35 confirms the presence of acidosis
caused by the accumulation of ketone bodies. Kussmaul respirations are the body’s
compensatory mechanism to blow off excess CO2.
, 4. The nurse is caring for a patient on the second postoperative day. Which finding suggests
the development of a deep vein thrombosis (DVT)?
A. Bilateral pitting edema in the ankles
B. Unilateral calf warmth and tenderness
C. Pale, cool skin on the affected extremity
D. Diminished pedal pulses in both feet
Answer: B
Rationale: DVT typically presents as unilateral swelling, redness, and localized warmth in
the lower extremity. While bilateral edema is often related to heart failure, unilateral
symptoms are a red flag for venous thrombus. Immediate notification of the provider is
required to prevent pulmonary embolism.
5. When administering Albuterol to a patient with an acute asthma attack, which side effect
should the nurse monitor for?
A. Bradycardia
B. Tachycardia and tremors
C. Lethargy and sleepiness
D. Hypoglycemia
Answer: B
