BSNC 2055 Final Review
Questions With Complete
Solutions
Course
BSNC 2055
Question 1
A nurse is assessing a patient with worsening heart failure. Which finding requires immediate
intervention?
A. Mild bilateral ankle edema
B. Oxygen saturation of 84% with crackles throughout both lungs
C. Weight gain of 1 lb over one week
D. Blood pressure of 146/86 mmHg
Correct Answer: B. Oxygen saturation of 84% with crackles throughout both lungs
Solution:
The patient is experiencing significant hypoxemia and pulmonary edema, indicating impaired
gas exchange. Airway and breathing take priority. The nurse should administer oxygen as
prescribed, position the patient upright, and notify the provider promptly.
Question 2
Which assessment finding is most consistent with hypovolemic shock?
A. Warm, flushed skin
B. Tachycardia, hypotension, and cool clammy skin
C. Bradycardia and hypertension
D. Bounding peripheral pulses
Correct Answer: B. Tachycardia, hypotension, and cool clammy skin
Solution:
Loss of circulating volume decreases tissue perfusion. The body compensates with tachycardia
and peripheral vasoconstriction, resulting in cool, clammy skin and hypotension.
,Question 3
A patient with diabetes suddenly becomes pale, diaphoretic, and confused. What should the nurse
do first?
A. Administer long-acting insulin
B. Check the blood glucose level immediately
C. Restrict oral fluids
D. Encourage ambulation
Correct Answer: B. Check the blood glucose level immediately
Solution:
These are classic symptoms of hypoglycemia. Confirming the blood glucose level guides
immediate treatment.
Question 4
Which electrolyte imbalance commonly causes peaked T waves on an electrocardiogram?
A. Hyponatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: B. Hyperkalemia
Solution:
Hyperkalemia alters cardiac conduction and can cause peaked T waves, widened QRS
complexes, and life-threatening dysrhythmias.
Question 5
Which patient should the nurse assess first?
A. Patient requesting pain medication
B. Patient with sudden onset chest pain radiating to the jaw
,C. Patient awaiting discharge teaching
D. Patient requesting assistance to the bathroom
Correct Answer: B. Patient with sudden onset chest pain radiating to the jaw
Solution:
This presentation is highly suggestive of acute coronary syndrome and requires immediate
assessment.
Question 6
A patient receiving IV morphine has a respiratory rate of 7 breaths/min. Which medication
should the nurse anticipate administering if prescribed?
A. Protamine sulfate
B. Naloxone
C. Vitamin K
D. Flumazenil
Correct Answer: B. Naloxone
Solution:
Naloxone is an opioid antagonist that reverses opioid-induced respiratory depression.
Question 7
Which laboratory test is routinely used to monitor warfarin therapy?
A. Activated partial thromboplastin time (aPTT)
B. International Normalized Ratio (INR)
C. Troponin
D. Serum creatinine
Correct Answer: B. International Normalized Ratio (INR)
Solution:
The INR helps determine whether warfarin is within the therapeutic range and guides dosage
adjustments.
, Question 8
A patient with COPD becomes increasingly drowsy and has a rising PaCO₂. What does this
finding suggest?
A. Improved respiratory function
B. Worsening ventilatory failure
C. Hyperventilation syndrome
D. Metabolic alkalosis
Correct Answer: B. Worsening ventilatory failure
Solution:
Increasing carbon dioxide retention and declining mental status indicate inadequate ventilation
and impending respiratory failure.
Question 9
Which nursing intervention helps prevent catheter-associated urinary tract infections?
A. Irrigate the catheter daily
B. Maintain a closed drainage system and remove the catheter as soon as possible
C. Disconnect the tubing every shift
D. Place the drainage bag on the bed
Correct Answer: B. Maintain a closed drainage system and remove the catheter as soon as
possible
Solution:
Limiting catheter duration and maintaining a closed system are evidence-based infection
prevention measures.
Question 10
Which assessment finding is expected in left-sided heart failure?
A. Hepatomegaly
Questions With Complete
Solutions
Course
BSNC 2055
Question 1
A nurse is assessing a patient with worsening heart failure. Which finding requires immediate
intervention?
A. Mild bilateral ankle edema
B. Oxygen saturation of 84% with crackles throughout both lungs
C. Weight gain of 1 lb over one week
D. Blood pressure of 146/86 mmHg
Correct Answer: B. Oxygen saturation of 84% with crackles throughout both lungs
Solution:
The patient is experiencing significant hypoxemia and pulmonary edema, indicating impaired
gas exchange. Airway and breathing take priority. The nurse should administer oxygen as
prescribed, position the patient upright, and notify the provider promptly.
Question 2
Which assessment finding is most consistent with hypovolemic shock?
A. Warm, flushed skin
B. Tachycardia, hypotension, and cool clammy skin
C. Bradycardia and hypertension
D. Bounding peripheral pulses
Correct Answer: B. Tachycardia, hypotension, and cool clammy skin
Solution:
Loss of circulating volume decreases tissue perfusion. The body compensates with tachycardia
and peripheral vasoconstriction, resulting in cool, clammy skin and hypotension.
,Question 3
A patient with diabetes suddenly becomes pale, diaphoretic, and confused. What should the nurse
do first?
A. Administer long-acting insulin
B. Check the blood glucose level immediately
C. Restrict oral fluids
D. Encourage ambulation
Correct Answer: B. Check the blood glucose level immediately
Solution:
These are classic symptoms of hypoglycemia. Confirming the blood glucose level guides
immediate treatment.
Question 4
Which electrolyte imbalance commonly causes peaked T waves on an electrocardiogram?
A. Hyponatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: B. Hyperkalemia
Solution:
Hyperkalemia alters cardiac conduction and can cause peaked T waves, widened QRS
complexes, and life-threatening dysrhythmias.
Question 5
Which patient should the nurse assess first?
A. Patient requesting pain medication
B. Patient with sudden onset chest pain radiating to the jaw
,C. Patient awaiting discharge teaching
D. Patient requesting assistance to the bathroom
Correct Answer: B. Patient with sudden onset chest pain radiating to the jaw
Solution:
This presentation is highly suggestive of acute coronary syndrome and requires immediate
assessment.
Question 6
A patient receiving IV morphine has a respiratory rate of 7 breaths/min. Which medication
should the nurse anticipate administering if prescribed?
A. Protamine sulfate
B. Naloxone
C. Vitamin K
D. Flumazenil
Correct Answer: B. Naloxone
Solution:
Naloxone is an opioid antagonist that reverses opioid-induced respiratory depression.
Question 7
Which laboratory test is routinely used to monitor warfarin therapy?
A. Activated partial thromboplastin time (aPTT)
B. International Normalized Ratio (INR)
C. Troponin
D. Serum creatinine
Correct Answer: B. International Normalized Ratio (INR)
Solution:
The INR helps determine whether warfarin is within the therapeutic range and guides dosage
adjustments.
, Question 8
A patient with COPD becomes increasingly drowsy and has a rising PaCO₂. What does this
finding suggest?
A. Improved respiratory function
B. Worsening ventilatory failure
C. Hyperventilation syndrome
D. Metabolic alkalosis
Correct Answer: B. Worsening ventilatory failure
Solution:
Increasing carbon dioxide retention and declining mental status indicate inadequate ventilation
and impending respiratory failure.
Question 9
Which nursing intervention helps prevent catheter-associated urinary tract infections?
A. Irrigate the catheter daily
B. Maintain a closed drainage system and remove the catheter as soon as possible
C. Disconnect the tubing every shift
D. Place the drainage bag on the bed
Correct Answer: B. Maintain a closed drainage system and remove the catheter as soon as
possible
Solution:
Limiting catheter duration and maintaining a closed system are evidence-based infection
prevention measures.
Question 10
Which assessment finding is expected in left-sided heart failure?
A. Hepatomegaly
