NUR 3300 Final Exam V3 | NUR 3300
Nursing Practice II | Q&A with Rationale
(NUR3300 Final Exam) | William Paterson
University
1. A patient with chronic kidney disease presents with a potassium level of 6.2 mEq/L. Which
nursing intervention is the highest priority for this patient?
A. Administering a prescribed dose of sodium polystyrene sulfonate.
B. Initiating continuous cardiac monitoring to detect dysrhythmias.
C. Educating the patient on low-potassium dietary choices.
D. Assessing the patient’s muscle strength and deep tendon reflexes.
Answer: B
Rationale: Hyperkalemia significantly increases the risk of life-threatening cardiac
dysrhythmias such as ventricular fibrillation or asystole. Continuous cardiac monitoring is
the priority to identify rhythm changes early and ensure patient safety. While other
interventions like medication administration and education are important, immediate
physiological stability takes precedence.
2. A nurse is caring for a postoperative patient who reports sudden chest pain and shortness
of breath. The nurse notes the patient is tachycardic and tachypneic. Which complication
should the nurse suspect first?
A. Pulmonary embolism from a deep vein thrombosis.
,B. Hypovolemic shock from internal bleeding.
C. Atelectasis due to shallow breathing.
D. Pneumonia secondary to decreased mobility.
Answer: A
Rationale: Sudden onset of chest pain, dyspnea, and tachycardia in a postoperative patient
are classic signs of a pulmonary embolism. This is a medical emergency where a blood clot
from the periphery travels to the lungs, obstructing blood flow. Immediate notification of
the healthcare provider and oxygen administration are critical nursing actions.
3. When assessing a patient with a suspected acid-base imbalance, the nurse notes the
following ABG results: pH 7.30, PaCO2 55 mmHg, and HCO3 26 mEq/L. How should the nurse
interpret these findings?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The pH is below the normal range of 7.35, indicating acidosis, and the PaCO2 is
elevated above 45 mmHg, indicating a respiratory cause. The bicarbonate level is within
the normal range, suggesting that the body has not yet compensated for the imbalance. This
,pattern is consistent with hypoventilation or obstructive lung disease where CO2 is
retained.
4. A patient is being prepared for a total hip replacement. Who is primarily responsible for
obtaining the signed informed consent?
A. The circulating nurse in the operating room.
B. The surgical technician assisting in the procedure.
C. The surgeon performing the operative procedure.
D. The nurse on the medical-surgical unit.
Answer: C
Rationale: It is the legal and ethical responsibility of the surgeon to explain the procedure,
risks, benefits, and alternatives to the patient. The nurse’s role is to witness the patient’s
signature and verify that the patient appears competent to give consent. If the patient has
questions about the surgery itself, the nurse must notify the surgeon to return and provide
further clarification.
5. The nurse is assessing a pressure injury on a patient’s sacrum and notes that the wound
involves full-thickness skin loss with visible subcutaneous fat, but no bone or muscle is
exposed. How should this be staged?
A. Stage II
B. Stage III
C. Stage IV
, D. Unstageable
Answer: B
Rationale: A Stage III pressure injury involves full-thickness tissue loss where
subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough or
eschar may be present but does not obscure the depth of tissue loss. It is important to
distinguish this from Stage IV, which involves exposed bone or muscle.
6. A patient with Type 1 Diabetes Mellitus presents with a blood glucose of 580 mg/dL and
positive ketones in the urine. Which fluid should the nurse expect to administer first?
A. 0.45% Normal Saline at 100 mL/hr.
B. 5% Dextrose in Water at 125 mL/hr.
C. Lactated Ringer’s solution at 75 mL/hr.
D. 0.9% Normal Saline at a rapid rate.
Answer: D
Rationale: In Diabetic Ketoacidosis (DKA), the patient is severely dehydrated due to
osmotic diuresis caused by hyperglycemia. Rehydration with isotonic saline (0.9% NS) is
the initial priority to restore circulatory volume and stabilize blood pressure. Insulin
therapy usually follows once fluid resuscitation has begun to avoid rapid shifts in
osmolarity.
7. Which of the following is the most reliable indicator of a patient’s fluid volume status?
A. Skin turgor and mucous membrane moisture.
Nursing Practice II | Q&A with Rationale
(NUR3300 Final Exam) | William Paterson
University
1. A patient with chronic kidney disease presents with a potassium level of 6.2 mEq/L. Which
nursing intervention is the highest priority for this patient?
A. Administering a prescribed dose of sodium polystyrene sulfonate.
B. Initiating continuous cardiac monitoring to detect dysrhythmias.
C. Educating the patient on low-potassium dietary choices.
D. Assessing the patient’s muscle strength and deep tendon reflexes.
Answer: B
Rationale: Hyperkalemia significantly increases the risk of life-threatening cardiac
dysrhythmias such as ventricular fibrillation or asystole. Continuous cardiac monitoring is
the priority to identify rhythm changes early and ensure patient safety. While other
interventions like medication administration and education are important, immediate
physiological stability takes precedence.
2. A nurse is caring for a postoperative patient who reports sudden chest pain and shortness
of breath. The nurse notes the patient is tachycardic and tachypneic. Which complication
should the nurse suspect first?
A. Pulmonary embolism from a deep vein thrombosis.
,B. Hypovolemic shock from internal bleeding.
C. Atelectasis due to shallow breathing.
D. Pneumonia secondary to decreased mobility.
Answer: A
Rationale: Sudden onset of chest pain, dyspnea, and tachycardia in a postoperative patient
are classic signs of a pulmonary embolism. This is a medical emergency where a blood clot
from the periphery travels to the lungs, obstructing blood flow. Immediate notification of
the healthcare provider and oxygen administration are critical nursing actions.
3. When assessing a patient with a suspected acid-base imbalance, the nurse notes the
following ABG results: pH 7.30, PaCO2 55 mmHg, and HCO3 26 mEq/L. How should the nurse
interpret these findings?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The pH is below the normal range of 7.35, indicating acidosis, and the PaCO2 is
elevated above 45 mmHg, indicating a respiratory cause. The bicarbonate level is within
the normal range, suggesting that the body has not yet compensated for the imbalance. This
,pattern is consistent with hypoventilation or obstructive lung disease where CO2 is
retained.
4. A patient is being prepared for a total hip replacement. Who is primarily responsible for
obtaining the signed informed consent?
A. The circulating nurse in the operating room.
B. The surgical technician assisting in the procedure.
C. The surgeon performing the operative procedure.
D. The nurse on the medical-surgical unit.
Answer: C
Rationale: It is the legal and ethical responsibility of the surgeon to explain the procedure,
risks, benefits, and alternatives to the patient. The nurse’s role is to witness the patient’s
signature and verify that the patient appears competent to give consent. If the patient has
questions about the surgery itself, the nurse must notify the surgeon to return and provide
further clarification.
5. The nurse is assessing a pressure injury on a patient’s sacrum and notes that the wound
involves full-thickness skin loss with visible subcutaneous fat, but no bone or muscle is
exposed. How should this be staged?
A. Stage II
B. Stage III
C. Stage IV
, D. Unstageable
Answer: B
Rationale: A Stage III pressure injury involves full-thickness tissue loss where
subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough or
eschar may be present but does not obscure the depth of tissue loss. It is important to
distinguish this from Stage IV, which involves exposed bone or muscle.
6. A patient with Type 1 Diabetes Mellitus presents with a blood glucose of 580 mg/dL and
positive ketones in the urine. Which fluid should the nurse expect to administer first?
A. 0.45% Normal Saline at 100 mL/hr.
B. 5% Dextrose in Water at 125 mL/hr.
C. Lactated Ringer’s solution at 75 mL/hr.
D. 0.9% Normal Saline at a rapid rate.
Answer: D
Rationale: In Diabetic Ketoacidosis (DKA), the patient is severely dehydrated due to
osmotic diuresis caused by hyperglycemia. Rehydration with isotonic saline (0.9% NS) is
the initial priority to restore circulatory volume and stabilize blood pressure. Insulin
therapy usually follows once fluid resuscitation has begun to avoid rapid shifts in
osmolarity.
7. Which of the following is the most reliable indicator of a patient’s fluid volume status?
A. Skin turgor and mucous membrane moisture.
