NR 229 Chamberlain College Of Nursing -NR 229 Exam 2 EXAM
with Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE - 1. Safe and Effective Care Environment: Safety
and Infection Control - 2. Health Promotion and Maintenance:
Physical Assessment and Lifespan Care - 3. Psychosocial Integrity:
Mental Health, Coping, and Therapeutic Communication - 4.
Physiological Integrity: Pathophysiology, Diagnostics,
Pharmacotherapy, and Nursing Interventions
1. A nurse is evaluating a 68-year-old patient admitted with acute decompensated heart failure who
is receiving intravenous furosemide. The patient reports sudden onset muscle weakness and
palpitations. The telemetry monitor demonstrates flattened T waves and prominent U waves.
Which laboratory finding requires immediate intervention?
A. Serum sodium level of 138 mEq/L
B. Serum potassium level of 2.8 mEq/L
C. Serum calcium level of 9.2 mg/dL
D. Serum magnesium level of 2.0 mEq/L
CORRECT ANSWER : B
Rationale: Loop diuretics such as furosemide cause significant potassium wasting in the renal
tubules, leading to severe hypokalemia characterized by muscle weakness, flattened T waves,
and prominent U waves on an ECG. A serum potassium level of 2.8 mEq/L places the patient at
high risk for fatal dysrhythmias and requires urgent intravenous replacement. Options A, C, and
D reflect serum electrolyte levels within normal reference ranges.
2. A clinical nurse specialist is auditing infection control compliance on a medical-surgical unit.
Which observation represents a critical breach in standard precaution protocols requiring
immediate remediation?
A. Performing hand hygiene with alcohol-based hand rub before touching a patient's intact skin
B. Decontaminating hands with alcohol-based rub after caring for a patient with
Clostridioides difficile
C. Wearing a fluid-resistant gown and face shield during an endotracheal suctioning procedure
, D. Doffing gloves and performing hand hygiene immediately prior to exiting an isolation room
CORRECT ANSWER : B
Rationale: Clostridioides difficile is a spore-forming organism resistant to alcohol-based hand
rubs, requiring physical removal via mechanical washing with soap and water. Relying on
alcohol rub after caring for a patient with C. difficile allows bacterial spores to persist and
spread. Options A, C, and D adhere strictly to evidence-based infection control and personal
protective equipment protocols.
3. An adult patient who underwent an open abdominal hysterectomy 24 hours ago reports severe
incisional pain rated 9 out of 10. The nurse notes shallow respirations at a rate of 10 breaths per
minute and an oxygen saturation of 91% on room air. What is the priority nursing action?
A. Administer the ordered intravenous opioid analgesic immediately
B. Assess airway patency, elevate the head of the bed, and encourage deep breathing
C. Apply a warm compress directly to the abdominal surgical incision
D. Document the respiratory rate and reassess the patient in two hours
CORRECT ANSWER : B
Rationale: The patient exhibits hypoventilation and mild hypoxemia, likely secondary to pain-
induced splinting and opioid administration. Elevating the head of the bed promotes lung
expansion and airway patency, addressing physiological instability before administering
additional respiratory-depressing analgesics. Administering opioids immediately without airway
intervention (Option A) could worsen respiratory depression, while Options C and D fail to
address the immediate oxygenation deficit.
4. A nurse caring for a patient with a left femoral shaft fracture notes a sudden onset of dyspnea,
confusion, and a petechial rash over the chest and anterior axillary folds 36 hours post-injury.
Which complication should the nurse suspect?
A. Deep vein thrombosis
B. Fat embolism syndrome
C. Pulmonary embolism secondary to blood clot
D. Acute compartment syndrome
CORRECT ANSWER : B
, Rationale: Fat embolism syndrome is a serious complication occurring 24 to 72 hours following
long bone fractures, classic for the triad of hypoxemia/dyspnea, neurological abnormalities
(confusion), and a pathognomonic petechial rash across the neck and chest. Deep vein
thrombosis and thromboembolism (Options A and C) cause dyspnea and chest pain but do not
typically manifest with petechiae. Compartment syndrome (Option D) presents with localized
neurovascular compromise in the extremity rather than systemic pulmonary and neurological
distress.
5. A patient with end-stage renal disease receiving hemodialysis through a right arteriovenous (AV)
fistula is being prepared for morning care and routine assessment. Which intervention by the
nursing assistive personnel (NAP) requires immediate intervention by the registered nurse?
A. Checking the capillary refill time in the right hand fingers
B. Obtaining a blood pressure reading on the right upper arm
C. Palpating a thrill over the right forearm vascular site
D. Auscultating a continuous bruit over the right AV fistula
CORRECT ANSWER : B
Rationale: Blood pressures, venipunctures, and intravenous lines must never be applied to an
extremity with an active AV fistula, as the compression can cause thrombosis, ischemia, or
destruction of the access site. Palpating a thrill (Option C) and auscultating a bruit (Option D)
are expected findings confirming fistula patency. Capillary refill assessment (Option A) is
appropriate to ensure peripheral perfusion.
6. A nurse is reviewing lab values for a patient receiving continuous IV heparin therapy for a
pulmonary embolism. The patient's baseline activated partial thromboplastin time (aPTT) was 30
seconds. Which current lab result indicates that the heparin dose is within the therapeutic range?
A. aPTT of 35 seconds
B. aPTT of 45 seconds
C. aPTT of 70 seconds
D. aPTT of 120 seconds
CORRECT ANSWER : C
Rationale: Therapeutic anticoagulation for heparin therapy is typically 1.5 to 2.5 times the
patient's baseline control value, making an aPTT of 60 to 75 seconds target for a 30-second
baseline. An aPTT of 35 or 45 seconds (Options A and B) is subtherapeutic and exposes the
, patient to clot extension. An aPTT of 120 seconds (Option D) exceeds therapeutic parameters
and places the patient at severe risk for hemorrhage.
7. An older adult patient with severe osteoarthritis is prescribed nonsteroidal anti-inflammatory
drugs (NSAIDs) for chronic pain management. Which diagnostic parameter should the nurse
monitor most closely to detect early drug-induced adverse effects?
A. Serum amylase and lipase
B. Serum creatinine and blood urea nitrogen
C. Serum bilirubin and alanine aminotransferase
D. Serum troponin and creatine kinase-MB
CORRECT ANSWER : B
Rationale: NSAIDs inhibit prostaglandin synthesis, which decreases renal blood flow and can
precipitate acute kidney injury, particularly in older adults. Monitoring serum creatinine and
blood urea nitrogen allows early identification of nephrotoxicity. While NSAIDs can cause
gastric ulceration, they do not primarily cause pancreatic (Option A) or cardiac (Option D)
enzyme elevations, and renal toxicity is a more immediate screening concern than hepatic
dysfunction (Option C).
8. A nurse enters the room of a patient receiving a blood transfusion and observes the patient
experiencing chills, fever, lower back pain, and dyspnea. The transfusion was initiated 15
minutes ago. What is the nurse's priority action?
A. Slow the infusion rate and re-check the patient's vital signs
B. Stop the blood transfusion immediately and disconnect the tubing at the hub
C. Administer prescribed IV diphenhydramine and continue monitoring
D. Notify the blood bank to request an alternative unit of blood
CORRECT ANSWER : B
Rationale: The patient exhibits classic signs of an acute hemolytic transfusion reaction, a life-
threatening emergency. The immediate priority is to stop the infusion to prevent further exposure
to incompatible red blood cells and disconnect the tubing to maintain vascular access with
normal saline via new tubing. Slowing the rate (Option A) or giving antihistamines while
continuing the transfusion (Option C) exposes the patient to lethal doses of antigen. Notification
of the blood bank (Option D) occurs after the infusion is safely stopped.
with Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE - 1. Safe and Effective Care Environment: Safety
and Infection Control - 2. Health Promotion and Maintenance:
Physical Assessment and Lifespan Care - 3. Psychosocial Integrity:
Mental Health, Coping, and Therapeutic Communication - 4.
Physiological Integrity: Pathophysiology, Diagnostics,
Pharmacotherapy, and Nursing Interventions
1. A nurse is evaluating a 68-year-old patient admitted with acute decompensated heart failure who
is receiving intravenous furosemide. The patient reports sudden onset muscle weakness and
palpitations. The telemetry monitor demonstrates flattened T waves and prominent U waves.
Which laboratory finding requires immediate intervention?
A. Serum sodium level of 138 mEq/L
B. Serum potassium level of 2.8 mEq/L
C. Serum calcium level of 9.2 mg/dL
D. Serum magnesium level of 2.0 mEq/L
CORRECT ANSWER : B
Rationale: Loop diuretics such as furosemide cause significant potassium wasting in the renal
tubules, leading to severe hypokalemia characterized by muscle weakness, flattened T waves,
and prominent U waves on an ECG. A serum potassium level of 2.8 mEq/L places the patient at
high risk for fatal dysrhythmias and requires urgent intravenous replacement. Options A, C, and
D reflect serum electrolyte levels within normal reference ranges.
2. A clinical nurse specialist is auditing infection control compliance on a medical-surgical unit.
Which observation represents a critical breach in standard precaution protocols requiring
immediate remediation?
A. Performing hand hygiene with alcohol-based hand rub before touching a patient's intact skin
B. Decontaminating hands with alcohol-based rub after caring for a patient with
Clostridioides difficile
C. Wearing a fluid-resistant gown and face shield during an endotracheal suctioning procedure
, D. Doffing gloves and performing hand hygiene immediately prior to exiting an isolation room
CORRECT ANSWER : B
Rationale: Clostridioides difficile is a spore-forming organism resistant to alcohol-based hand
rubs, requiring physical removal via mechanical washing with soap and water. Relying on
alcohol rub after caring for a patient with C. difficile allows bacterial spores to persist and
spread. Options A, C, and D adhere strictly to evidence-based infection control and personal
protective equipment protocols.
3. An adult patient who underwent an open abdominal hysterectomy 24 hours ago reports severe
incisional pain rated 9 out of 10. The nurse notes shallow respirations at a rate of 10 breaths per
minute and an oxygen saturation of 91% on room air. What is the priority nursing action?
A. Administer the ordered intravenous opioid analgesic immediately
B. Assess airway patency, elevate the head of the bed, and encourage deep breathing
C. Apply a warm compress directly to the abdominal surgical incision
D. Document the respiratory rate and reassess the patient in two hours
CORRECT ANSWER : B
Rationale: The patient exhibits hypoventilation and mild hypoxemia, likely secondary to pain-
induced splinting and opioid administration. Elevating the head of the bed promotes lung
expansion and airway patency, addressing physiological instability before administering
additional respiratory-depressing analgesics. Administering opioids immediately without airway
intervention (Option A) could worsen respiratory depression, while Options C and D fail to
address the immediate oxygenation deficit.
4. A nurse caring for a patient with a left femoral shaft fracture notes a sudden onset of dyspnea,
confusion, and a petechial rash over the chest and anterior axillary folds 36 hours post-injury.
Which complication should the nurse suspect?
A. Deep vein thrombosis
B. Fat embolism syndrome
C. Pulmonary embolism secondary to blood clot
D. Acute compartment syndrome
CORRECT ANSWER : B
, Rationale: Fat embolism syndrome is a serious complication occurring 24 to 72 hours following
long bone fractures, classic for the triad of hypoxemia/dyspnea, neurological abnormalities
(confusion), and a pathognomonic petechial rash across the neck and chest. Deep vein
thrombosis and thromboembolism (Options A and C) cause dyspnea and chest pain but do not
typically manifest with petechiae. Compartment syndrome (Option D) presents with localized
neurovascular compromise in the extremity rather than systemic pulmonary and neurological
distress.
5. A patient with end-stage renal disease receiving hemodialysis through a right arteriovenous (AV)
fistula is being prepared for morning care and routine assessment. Which intervention by the
nursing assistive personnel (NAP) requires immediate intervention by the registered nurse?
A. Checking the capillary refill time in the right hand fingers
B. Obtaining a blood pressure reading on the right upper arm
C. Palpating a thrill over the right forearm vascular site
D. Auscultating a continuous bruit over the right AV fistula
CORRECT ANSWER : B
Rationale: Blood pressures, venipunctures, and intravenous lines must never be applied to an
extremity with an active AV fistula, as the compression can cause thrombosis, ischemia, or
destruction of the access site. Palpating a thrill (Option C) and auscultating a bruit (Option D)
are expected findings confirming fistula patency. Capillary refill assessment (Option A) is
appropriate to ensure peripheral perfusion.
6. A nurse is reviewing lab values for a patient receiving continuous IV heparin therapy for a
pulmonary embolism. The patient's baseline activated partial thromboplastin time (aPTT) was 30
seconds. Which current lab result indicates that the heparin dose is within the therapeutic range?
A. aPTT of 35 seconds
B. aPTT of 45 seconds
C. aPTT of 70 seconds
D. aPTT of 120 seconds
CORRECT ANSWER : C
Rationale: Therapeutic anticoagulation for heparin therapy is typically 1.5 to 2.5 times the
patient's baseline control value, making an aPTT of 60 to 75 seconds target for a 30-second
baseline. An aPTT of 35 or 45 seconds (Options A and B) is subtherapeutic and exposes the
, patient to clot extension. An aPTT of 120 seconds (Option D) exceeds therapeutic parameters
and places the patient at severe risk for hemorrhage.
7. An older adult patient with severe osteoarthritis is prescribed nonsteroidal anti-inflammatory
drugs (NSAIDs) for chronic pain management. Which diagnostic parameter should the nurse
monitor most closely to detect early drug-induced adverse effects?
A. Serum amylase and lipase
B. Serum creatinine and blood urea nitrogen
C. Serum bilirubin and alanine aminotransferase
D. Serum troponin and creatine kinase-MB
CORRECT ANSWER : B
Rationale: NSAIDs inhibit prostaglandin synthesis, which decreases renal blood flow and can
precipitate acute kidney injury, particularly in older adults. Monitoring serum creatinine and
blood urea nitrogen allows early identification of nephrotoxicity. While NSAIDs can cause
gastric ulceration, they do not primarily cause pancreatic (Option A) or cardiac (Option D)
enzyme elevations, and renal toxicity is a more immediate screening concern than hepatic
dysfunction (Option C).
8. A nurse enters the room of a patient receiving a blood transfusion and observes the patient
experiencing chills, fever, lower back pain, and dyspnea. The transfusion was initiated 15
minutes ago. What is the nurse's priority action?
A. Slow the infusion rate and re-check the patient's vital signs
B. Stop the blood transfusion immediately and disconnect the tubing at the hub
C. Administer prescribed IV diphenhydramine and continue monitoring
D. Notify the blood bank to request an alternative unit of blood
CORRECT ANSWER : B
Rationale: The patient exhibits classic signs of an acute hemolytic transfusion reaction, a life-
threatening emergency. The immediate priority is to stop the infusion to prevent further exposure
to incompatible red blood cells and disconnect the tubing to maintain vascular access with
normal saline via new tubing. Slowing the rate (Option A) or giving antihistamines while
continuing the transfusion (Option C) exposes the patient to lethal doses of antigen. Notification
of the blood bank (Option D) occurs after the infusion is safely stopped.
