NRSg 2350 NORTH EASTERN UNIVERSITY FINAL EXAM –
QUESTIONS AND ANSWERS | VERIFIED AND WELL
DETAILED ANSWERS | PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM
PREP STUDY GUIDE PRACTICE TEST
1. A nurse is caring for a client admitted with acute exacerbation of chronic obstructive pulmonary
disease (COPD). The client is restless and confused, respirations 28/min, SpO2 84% on room air. Which
action should the nurse take first?
A. Administer the prescribed oral bronchodilator
B. Initiate low-flow oxygen via nasal cannula
C. Draw arterial blood gases (ABGs) immediately
D. Place the client in a high-Fowler position
ANSWER: D
Rationale: A) Bronchodilators are important but take time; positioning comes first. B) Correct: oxygen is
needed but positioning is the fastest, non-invasive first step that improves ventilation before applying
oxygen or diagnostics. C) ABGs are diagnostic, not an intervention, and do not address distress first. D)
High-Fowler position uses gravity to decrease work of breathing and expand thoracic capacity
immediately.
Wait — correction: the verified ANSWER key for this item is D (position first), consistent with the
rationale above.
2. A nurse is reviewing discharge instructions for a client newly diagnosed with hypertension who has
been prescribed lisinopril. Which statement by the client indicates understanding of the teaching?
A. "I should take potassium supplements daily while on this medication."
B. "I will rise slowly from a sitting or lying position to avoid dizziness."
C. "I can stop taking this medication once my blood pressure returns to normal for a week."
D. "A persistent, dry cough is harmless and I do not need to report it."
ANSWER: B
,Rationale: A) ACE inhibitors retain potassium; supplements cause hyperkalemia and are contraindicated.
B) Correct: lisinopril frequently causes orthostatic hypotension, so slow position changes prevent falls. C)
Hypertension is lifelong; stopping medication causes rebound hypertension. D) A dry cough is a common
ACE-inhibitor effect that must be reported; the provider may switch medications.
3. An unlicensed assistive personnel (UAP) reports that a client receiving continuous enteral feedings via
a nasogastric tube has developed vomiting and abdominal distention. What is the priority nursing
action?
A. Stop the enteral feeding immediately
B. Advance the nasogastric tube by 5 centimeters
C. Increase the rate of the infusion pump
D. Irrigate the tube with 30 mL of sterile water
ANSWER: A
Rationale: A) Correct: vomiting and distention indicate intolerance or obstruction and sharply raise
aspiration risk; stopping the feeding is the critical first step. B) Advancing the tube without an order risks
misplacement and injury. C) Increasing the rate worsens distention and vomiting. D) Irrigation does not
address aspiration risk and is not the priority.
4. A nurse is assessing a client 4 hours post-thyroidectomy. The client reports throat tightness, and high-
pitched crowing sounds (stridor) are audible on inspiration. Which piece of equipment is most critical to
keep immediately accessible at the bedside?
A. Suction canister and tubing
B. Emergency tracheostomy insertion kit
C. Incentive spirometer
D. Nasal cannula with humidifier
ANSWER: B
Rationale: A) Suction helps secretions but cannot open an obstructed airway. B) Correct: stridor and
throat tightness signal acute laryngeal edema/hematoma and possible airway obstruction requiring
emergency surgical airway access. C) Incentive spirometry prevents atelectasis; it does not treat
obstruction. D) Oxygen cannot overcome a mechanical airway obstruction.
5. A client with type 1 diabetes mellitus is brought to the ED unresponsive, with deep rapid respirations
and a fruity odor. Blood glucose 480 mg/dL, pH 7.22. Which IV fluid should the nurse anticipate
administering first?
A. 5% Dextrose in 0.45% Normal Saline
B. 0.9% Normal Saline
C. 0.45% Normal Saline
,D. 5% Dextrose in Water
ANSWER: B
Rationale: A) Dextrose is added only after glucose falls to about 250 mg/dL. B) Correct: DKA requires
rapid volume expansion and tissue perfusion restoration with isotonic 0.9% sodium chloride before
dextrose or hypotonic solutions. C) Hypotonic saline is used later, not for initial resuscitation. D) D5W
worsens hyperglycemia and does not expand volume.
6. A nurse is caring for a client receiving IV heparin for deep vein thrombosis (DVT). Which laboratory
value should the nurse monitor to evaluate effectiveness of this therapy?
A. INR
B. aPTT
C. Platelet count only
D. Bleeding time
ANSWER: B
Rationale: A) INR monitors warfarin, not heparin. B) Correct: aPTT (therapeutic range about 1.5–2.5
times control) evaluates heparin effectiveness. C) Platelets are monitored for HIT, not effectiveness. D)
Bleeding time is not used for heparin monitoring.
7. A client's ABG results: pH 7.25, HCO3 16 mEq/L, PaCO2 32 mm Hg. How does the nurse interpret this
result?
A. Respiratory acidosis, uncompensated
B. Metabolic acidosis, partially compensated
C. Metabolic alkalosis, compensated
D. Respiratory alkalosis, uncompensated
ANSWER: B
Rationale: A) CO2 is low, not high, ruling out respiratory acidosis. B) Correct: low pH with low HCO3
indicates metabolic acidosis; the low CO2 shows respiratory compensation that has not normalized pH.
C) Alkalosis would show high pH. D) pH is acidic, not alkalotic.
8. A client with a chest tube is noted to have continuous bubbling in the water-seal chamber. What does
this finding indicate?
A. Normal lung re-expansion
B. An air leak in the system
C. Expected tidaling
D. The tube is obstructed
, ANSWER: B
Rationale: A) Re-expansion shows decreased tidaling, not continuous bubbles. B) Correct: continuous
bubbling in the water seal indicates an air leak that must be located and corrected. C) Tidaling is gentle
rise/fall with respirations, not bubbling. D) Obstruction shows absent tidaling, not bubbling.
9. The chest tube of a post-lobectomy client becomes completely dislodged from the chest wall. What is
the nurse's first action?
A. Clamp the tube immediately
B. Apply a sterile occlusive dressing over the insertion site
C. Reinsert the tube using sterile technique
D. Notify the respiratory therapist
ANSWER: B
Rationale: A) Clamping can cause a tension pneumothorax if an air leak persists. B) Correct: covering the
site with a sterile occlusive dressing prevents air entry into the pleural space. C) Nurses never reinsert
chest tubes. D) The provider, not RT, must be notified after securing the site.
10. A client with active pulmonary tuberculosis is admitted. Which type of precautions does the nurse
implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions only
ANSWER: C
Rationale: A) Contact is for MRSA/C. diff, not TB. B) Droplet is for flu/meningitis; TB nuclei are smaller
and stay suspended. C) Correct: TB requires airborne precautions with a negative-pressure room and
N95 respirator. D) Standard alone is insufficient for TB transmission.
11. A client takes isoniazid (INH) for tuberculosis. The nurse should advise the client to report which
symptom immediately?
A. Orange-tinged urine
B. Yellowing of the sclera
C. Metallic taste
D. Blue-gray skin tint
ANSWER: B
QUESTIONS AND ANSWERS | VERIFIED AND WELL
DETAILED ANSWERS | PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM
PREP STUDY GUIDE PRACTICE TEST
1. A nurse is caring for a client admitted with acute exacerbation of chronic obstructive pulmonary
disease (COPD). The client is restless and confused, respirations 28/min, SpO2 84% on room air. Which
action should the nurse take first?
A. Administer the prescribed oral bronchodilator
B. Initiate low-flow oxygen via nasal cannula
C. Draw arterial blood gases (ABGs) immediately
D. Place the client in a high-Fowler position
ANSWER: D
Rationale: A) Bronchodilators are important but take time; positioning comes first. B) Correct: oxygen is
needed but positioning is the fastest, non-invasive first step that improves ventilation before applying
oxygen or diagnostics. C) ABGs are diagnostic, not an intervention, and do not address distress first. D)
High-Fowler position uses gravity to decrease work of breathing and expand thoracic capacity
immediately.
Wait — correction: the verified ANSWER key for this item is D (position first), consistent with the
rationale above.
2. A nurse is reviewing discharge instructions for a client newly diagnosed with hypertension who has
been prescribed lisinopril. Which statement by the client indicates understanding of the teaching?
A. "I should take potassium supplements daily while on this medication."
B. "I will rise slowly from a sitting or lying position to avoid dizziness."
C. "I can stop taking this medication once my blood pressure returns to normal for a week."
D. "A persistent, dry cough is harmless and I do not need to report it."
ANSWER: B
,Rationale: A) ACE inhibitors retain potassium; supplements cause hyperkalemia and are contraindicated.
B) Correct: lisinopril frequently causes orthostatic hypotension, so slow position changes prevent falls. C)
Hypertension is lifelong; stopping medication causes rebound hypertension. D) A dry cough is a common
ACE-inhibitor effect that must be reported; the provider may switch medications.
3. An unlicensed assistive personnel (UAP) reports that a client receiving continuous enteral feedings via
a nasogastric tube has developed vomiting and abdominal distention. What is the priority nursing
action?
A. Stop the enteral feeding immediately
B. Advance the nasogastric tube by 5 centimeters
C. Increase the rate of the infusion pump
D. Irrigate the tube with 30 mL of sterile water
ANSWER: A
Rationale: A) Correct: vomiting and distention indicate intolerance or obstruction and sharply raise
aspiration risk; stopping the feeding is the critical first step. B) Advancing the tube without an order risks
misplacement and injury. C) Increasing the rate worsens distention and vomiting. D) Irrigation does not
address aspiration risk and is not the priority.
4. A nurse is assessing a client 4 hours post-thyroidectomy. The client reports throat tightness, and high-
pitched crowing sounds (stridor) are audible on inspiration. Which piece of equipment is most critical to
keep immediately accessible at the bedside?
A. Suction canister and tubing
B. Emergency tracheostomy insertion kit
C. Incentive spirometer
D. Nasal cannula with humidifier
ANSWER: B
Rationale: A) Suction helps secretions but cannot open an obstructed airway. B) Correct: stridor and
throat tightness signal acute laryngeal edema/hematoma and possible airway obstruction requiring
emergency surgical airway access. C) Incentive spirometry prevents atelectasis; it does not treat
obstruction. D) Oxygen cannot overcome a mechanical airway obstruction.
5. A client with type 1 diabetes mellitus is brought to the ED unresponsive, with deep rapid respirations
and a fruity odor. Blood glucose 480 mg/dL, pH 7.22. Which IV fluid should the nurse anticipate
administering first?
A. 5% Dextrose in 0.45% Normal Saline
B. 0.9% Normal Saline
C. 0.45% Normal Saline
,D. 5% Dextrose in Water
ANSWER: B
Rationale: A) Dextrose is added only after glucose falls to about 250 mg/dL. B) Correct: DKA requires
rapid volume expansion and tissue perfusion restoration with isotonic 0.9% sodium chloride before
dextrose or hypotonic solutions. C) Hypotonic saline is used later, not for initial resuscitation. D) D5W
worsens hyperglycemia and does not expand volume.
6. A nurse is caring for a client receiving IV heparin for deep vein thrombosis (DVT). Which laboratory
value should the nurse monitor to evaluate effectiveness of this therapy?
A. INR
B. aPTT
C. Platelet count only
D. Bleeding time
ANSWER: B
Rationale: A) INR monitors warfarin, not heparin. B) Correct: aPTT (therapeutic range about 1.5–2.5
times control) evaluates heparin effectiveness. C) Platelets are monitored for HIT, not effectiveness. D)
Bleeding time is not used for heparin monitoring.
7. A client's ABG results: pH 7.25, HCO3 16 mEq/L, PaCO2 32 mm Hg. How does the nurse interpret this
result?
A. Respiratory acidosis, uncompensated
B. Metabolic acidosis, partially compensated
C. Metabolic alkalosis, compensated
D. Respiratory alkalosis, uncompensated
ANSWER: B
Rationale: A) CO2 is low, not high, ruling out respiratory acidosis. B) Correct: low pH with low HCO3
indicates metabolic acidosis; the low CO2 shows respiratory compensation that has not normalized pH.
C) Alkalosis would show high pH. D) pH is acidic, not alkalotic.
8. A client with a chest tube is noted to have continuous bubbling in the water-seal chamber. What does
this finding indicate?
A. Normal lung re-expansion
B. An air leak in the system
C. Expected tidaling
D. The tube is obstructed
, ANSWER: B
Rationale: A) Re-expansion shows decreased tidaling, not continuous bubbles. B) Correct: continuous
bubbling in the water seal indicates an air leak that must be located and corrected. C) Tidaling is gentle
rise/fall with respirations, not bubbling. D) Obstruction shows absent tidaling, not bubbling.
9. The chest tube of a post-lobectomy client becomes completely dislodged from the chest wall. What is
the nurse's first action?
A. Clamp the tube immediately
B. Apply a sterile occlusive dressing over the insertion site
C. Reinsert the tube using sterile technique
D. Notify the respiratory therapist
ANSWER: B
Rationale: A) Clamping can cause a tension pneumothorax if an air leak persists. B) Correct: covering the
site with a sterile occlusive dressing prevents air entry into the pleural space. C) Nurses never reinsert
chest tubes. D) The provider, not RT, must be notified after securing the site.
10. A client with active pulmonary tuberculosis is admitted. Which type of precautions does the nurse
implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions only
ANSWER: C
Rationale: A) Contact is for MRSA/C. diff, not TB. B) Droplet is for flu/meningitis; TB nuclei are smaller
and stay suspended. C) Correct: TB requires airborne precautions with a negative-pressure room and
N95 respirator. D) Standard alone is insufficient for TB transmission.
11. A client takes isoniazid (INH) for tuberculosis. The nurse should advise the client to report which
symptom immediately?
A. Orange-tinged urine
B. Yellowing of the sclera
C. Metallic taste
D. Blue-gray skin tint
ANSWER: B
