,South College NSG 2610 Exam 2 | Adult Health
Nursing II (2026) Q&A
1. A patient with heart failure is prescribed furosemide and digoxin. Which laboratory
value is most important for the nurse to monitor before administering these
medications?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Correct Answer: Serum potassium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. Low potassium
levels increase the risk of digoxin toxicity because digoxin and potassium compete
for the same binding sites on the sodium-potassium ATPase pump. Monitoring
serum potassium is crucial to prevent life-threatening dysrhythmias.
2. A client with COPD has an arterial blood gas result showing pH 7.32, PaCO2 58 mm
Hg, and HCO3- 30 mEq/L. The nurse interprets this as:
A) Uncompensated respiratory acidosis
B) Partially compensated respiratory acidosis
C) Fully compensated respiratory acidosis
D) Uncompensated metabolic alkalosis
Correct Answer: Partially compensated respiratory acidosis
,Rationale: The pH is low (acidosis) and the PaCO2 is elevated (respiratory cause). The
HCO3- is elevated (30 mEq/L), indicating the kidneys are attempting to compensate
by retaining bicarbonate. However, because the pH is still abnormal, this is a partially
compensated respiratory acidosis. If it were fully compensated, the pH would be
within the normal range.
3. A nurse is caring for a patient receiving mechanical ventilation. Which assessment
finding indicates a potential complication of positive pressure ventilation?
A) Blood pressure 140/88 mm Hg
B) Heart rate 88 beats/min
C) Decreased urine output
D) SpO2 of 96%
Correct Answer: Decreased urine output
Rationale: Positive pressure ventilation increases intrathoracic pressure, which can
decrease venous return to the heart, reducing cardiac output. This leads to decreased
renal perfusion and, consequently, decreased urine output. This is a sign of potential
hypotension and reduced cardiac output.
4. A patient has a chest tube inserted for a pneumothorax. The nurse notes
continuous bubbling in the water seal chamber. What is the most appropriate initial
action?
A) Clamp the chest tube
B) Assess the patient's respiratory status and the system for an air leak
C) Increase the suction pressure
D) Immediately notify the healthcare provider
Correct Answer: Assess the patient's respiratory status and the system for an air leak
, Rationale: Continuous bubbling in the water seal chamber indicates an air leak. The
priority is to assess the patient for respiratory distress and assess the chest tube
system to find the source of the leak (e.g., loose connections). Clamping the tube
could lead to a tension pneumothorax. Notification of the provider is important, but
after the initial assessment.
5. Which of the following is a contraindication for the administration of t-PA (tissue
plasminogen activator) in a patient with acute ischemic stroke?
A) Onset of stroke symptoms 2 hours ago
B) Blood pressure 150/90 mm Hg
C) History of a hemorrhagic stroke 6 months ago
D) Patient is 65 years old
Correct Answer: History of a hemorrhagic stroke 6 months ago
Rationale: A history of a hemorrhagic stroke at any time is a contraindication for t-
PA due to the significant risk of causing bleeding. Onset of symptoms within 3 hours
and a manageable blood pressure (<185/110 mm Hg) are not absolute
contraindications. Age is not a contraindication.
6. A patient with acute decompensated heart failure (ADHF) presents with crackles in
the lungs, jugular vein distension, and peripheral edema. Which nursing diagnosis
has the highest priority?
A) Excess Fluid Volume
B) Activity Intolerance
C) Impaired Gas Exchange
D) Anxiety
Nursing II (2026) Q&A
1. A patient with heart failure is prescribed furosemide and digoxin. Which laboratory
value is most important for the nurse to monitor before administering these
medications?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Correct Answer: Serum potassium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. Low potassium
levels increase the risk of digoxin toxicity because digoxin and potassium compete
for the same binding sites on the sodium-potassium ATPase pump. Monitoring
serum potassium is crucial to prevent life-threatening dysrhythmias.
2. A client with COPD has an arterial blood gas result showing pH 7.32, PaCO2 58 mm
Hg, and HCO3- 30 mEq/L. The nurse interprets this as:
A) Uncompensated respiratory acidosis
B) Partially compensated respiratory acidosis
C) Fully compensated respiratory acidosis
D) Uncompensated metabolic alkalosis
Correct Answer: Partially compensated respiratory acidosis
,Rationale: The pH is low (acidosis) and the PaCO2 is elevated (respiratory cause). The
HCO3- is elevated (30 mEq/L), indicating the kidneys are attempting to compensate
by retaining bicarbonate. However, because the pH is still abnormal, this is a partially
compensated respiratory acidosis. If it were fully compensated, the pH would be
within the normal range.
3. A nurse is caring for a patient receiving mechanical ventilation. Which assessment
finding indicates a potential complication of positive pressure ventilation?
A) Blood pressure 140/88 mm Hg
B) Heart rate 88 beats/min
C) Decreased urine output
D) SpO2 of 96%
Correct Answer: Decreased urine output
Rationale: Positive pressure ventilation increases intrathoracic pressure, which can
decrease venous return to the heart, reducing cardiac output. This leads to decreased
renal perfusion and, consequently, decreased urine output. This is a sign of potential
hypotension and reduced cardiac output.
4. A patient has a chest tube inserted for a pneumothorax. The nurse notes
continuous bubbling in the water seal chamber. What is the most appropriate initial
action?
A) Clamp the chest tube
B) Assess the patient's respiratory status and the system for an air leak
C) Increase the suction pressure
D) Immediately notify the healthcare provider
Correct Answer: Assess the patient's respiratory status and the system for an air leak
, Rationale: Continuous bubbling in the water seal chamber indicates an air leak. The
priority is to assess the patient for respiratory distress and assess the chest tube
system to find the source of the leak (e.g., loose connections). Clamping the tube
could lead to a tension pneumothorax. Notification of the provider is important, but
after the initial assessment.
5. Which of the following is a contraindication for the administration of t-PA (tissue
plasminogen activator) in a patient with acute ischemic stroke?
A) Onset of stroke symptoms 2 hours ago
B) Blood pressure 150/90 mm Hg
C) History of a hemorrhagic stroke 6 months ago
D) Patient is 65 years old
Correct Answer: History of a hemorrhagic stroke 6 months ago
Rationale: A history of a hemorrhagic stroke at any time is a contraindication for t-
PA due to the significant risk of causing bleeding. Onset of symptoms within 3 hours
and a manageable blood pressure (<185/110 mm Hg) are not absolute
contraindications. Age is not a contraindication.
6. A patient with acute decompensated heart failure (ADHF) presents with crackles in
the lungs, jugular vein distension, and peripheral edema. Which nursing diagnosis
has the highest priority?
A) Excess Fluid Volume
B) Activity Intolerance
C) Impaired Gas Exchange
D) Anxiety
