NURS 507 Final Exam verified with correct answers with rationales A+
Graded/instant pdf
1. A 72-year-old patient with heart failure presents with increasing dyspnea, bilateral crackles,
jugular venous distention, and 3+ pitting edema. What is the priority nursing intervention?
A. Encourage oral fluids
B. Administer prescribed IV furosemide and monitor urine output
C. Place the patient flat in bed
D. Restrict oxygen therapy
Correct Answer: B
Rationale: The patient is demonstrating signs of acute fluid volume overload. Prompt administration of a
loop diuretic helps reduce preload, improve pulmonary congestion, and relieve symptoms.
2. Which laboratory value is most concerning in a patient receiving spironolactone?
A. Sodium 140 mEq/L
B. Potassium 6.2 mEq/L
C. Chloride 101 mEq/L
D. Calcium 9.3 mg/dL
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic. Hyperkalemia can lead to life-threatening
cardiac dysrhythmias.
3. Which finding is most indicative of septic shock?
A. Warm skin and normal blood pressure
B. Persistent hypotension despite adequate fluid resuscitation
C. Bradycardia with hypertension
D. Increased urine output
Correct Answer: B
,Rationale: Septic shock is characterized by hypotension that persists despite adequate fluid replacement
and often requires vasopressors.
4. A patient with COPD suddenly becomes restless and confused. What is the nurse's first action?
A. Notify the family
B. Assess airway, breathing, and oxygen saturation
C. Administer a sedative
D. Encourage oral fluids
Correct Answer: B
Rationale: Restlessness and confusion are early indicators of hypoxemia. Immediate respiratory
assessment is essential.
5. A patient receiving morphine has a respiratory rate of 7 breaths/minute. Which medication
should the nurse prepare to administer?
A. Flumazenil
B. Protamine sulfate
C. Naloxone
D. Vitamin K
Correct Answer: C
Rationale: Naloxone is the opioid antagonist used to reverse opioid-induced respiratory depression.
6. Which assessment finding suggests acute pulmonary edema?
A. Dry cough
B. Pink frothy sputum
C. Constipation
D. Bradycardia
,Correct Answer: B
Rationale: Pink frothy sputum is a classic manifestation of acute pulmonary edema associated with left-
sided heart failure.
7. A patient develops sudden unilateral weakness and difficulty speaking. What is the priority
intervention?
A. Administer insulin
B. Activate the stroke protocol
C. Obtain informed consent
D. Encourage rest
Correct Answer: B
Rationale: Immediate activation of the stroke protocol expedites imaging and treatment for eligible
patients.
8. Which electrolyte imbalance commonly causes peaked T waves?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Correct Answer: B
Rationale: Hyperkalemia affects cardiac conduction and produces peaked T waves on ECG.
9. A patient has diabetic ketoacidosis. Which intervention is the highest priority?
A. Restrict fluids
B. Begin isotonic IV fluid replacement
C. Encourage ambulation
, D. Administer oral glucose
Correct Answer: B
Rationale: Fluid replacement is the initial priority because severe dehydration accompanies DKA.
10. Which laboratory test best evaluates long-term glucose control?
A. Random glucose
B. Hemoglobin A1C
C. Fasting insulin
D. Serum ketones
Correct Answer: B
Rationale: Hemoglobin A1C reflects average blood glucose over approximately 2–3 months.
11. A patient receiving warfarin has an INR of 6.0. What should the nurse do first?
A. Administer another dose
B. Hold warfarin and notify the healthcare provider
C. Encourage green leafy vegetables
D. Encourage ambulation
Correct Answer: B
Rationale: An INR of 6.0 significantly increases bleeding risk and warrants withholding the medication
while the provider is notified.
12. Which finding is most concerning after thyroidectomy?
A. Mild sore throat
B. Stridor
C. Hoarseness that improves with fluids
Graded/instant pdf
1. A 72-year-old patient with heart failure presents with increasing dyspnea, bilateral crackles,
jugular venous distention, and 3+ pitting edema. What is the priority nursing intervention?
A. Encourage oral fluids
B. Administer prescribed IV furosemide and monitor urine output
C. Place the patient flat in bed
D. Restrict oxygen therapy
Correct Answer: B
Rationale: The patient is demonstrating signs of acute fluid volume overload. Prompt administration of a
loop diuretic helps reduce preload, improve pulmonary congestion, and relieve symptoms.
2. Which laboratory value is most concerning in a patient receiving spironolactone?
A. Sodium 140 mEq/L
B. Potassium 6.2 mEq/L
C. Chloride 101 mEq/L
D. Calcium 9.3 mg/dL
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic. Hyperkalemia can lead to life-threatening
cardiac dysrhythmias.
3. Which finding is most indicative of septic shock?
A. Warm skin and normal blood pressure
B. Persistent hypotension despite adequate fluid resuscitation
C. Bradycardia with hypertension
D. Increased urine output
Correct Answer: B
,Rationale: Septic shock is characterized by hypotension that persists despite adequate fluid replacement
and often requires vasopressors.
4. A patient with COPD suddenly becomes restless and confused. What is the nurse's first action?
A. Notify the family
B. Assess airway, breathing, and oxygen saturation
C. Administer a sedative
D. Encourage oral fluids
Correct Answer: B
Rationale: Restlessness and confusion are early indicators of hypoxemia. Immediate respiratory
assessment is essential.
5. A patient receiving morphine has a respiratory rate of 7 breaths/minute. Which medication
should the nurse prepare to administer?
A. Flumazenil
B. Protamine sulfate
C. Naloxone
D. Vitamin K
Correct Answer: C
Rationale: Naloxone is the opioid antagonist used to reverse opioid-induced respiratory depression.
6. Which assessment finding suggests acute pulmonary edema?
A. Dry cough
B. Pink frothy sputum
C. Constipation
D. Bradycardia
,Correct Answer: B
Rationale: Pink frothy sputum is a classic manifestation of acute pulmonary edema associated with left-
sided heart failure.
7. A patient develops sudden unilateral weakness and difficulty speaking. What is the priority
intervention?
A. Administer insulin
B. Activate the stroke protocol
C. Obtain informed consent
D. Encourage rest
Correct Answer: B
Rationale: Immediate activation of the stroke protocol expedites imaging and treatment for eligible
patients.
8. Which electrolyte imbalance commonly causes peaked T waves?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Correct Answer: B
Rationale: Hyperkalemia affects cardiac conduction and produces peaked T waves on ECG.
9. A patient has diabetic ketoacidosis. Which intervention is the highest priority?
A. Restrict fluids
B. Begin isotonic IV fluid replacement
C. Encourage ambulation
, D. Administer oral glucose
Correct Answer: B
Rationale: Fluid replacement is the initial priority because severe dehydration accompanies DKA.
10. Which laboratory test best evaluates long-term glucose control?
A. Random glucose
B. Hemoglobin A1C
C. Fasting insulin
D. Serum ketones
Correct Answer: B
Rationale: Hemoglobin A1C reflects average blood glucose over approximately 2–3 months.
11. A patient receiving warfarin has an INR of 6.0. What should the nurse do first?
A. Administer another dose
B. Hold warfarin and notify the healthcare provider
C. Encourage green leafy vegetables
D. Encourage ambulation
Correct Answer: B
Rationale: An INR of 6.0 significantly increases bleeding risk and warrants withholding the medication
while the provider is notified.
12. Which finding is most concerning after thyroidectomy?
A. Mild sore throat
B. Stridor
C. Hoarseness that improves with fluids
