NSG 4800 COMPS EXAM 2 – QUESTIONS COMPLETE WITH
100% VERIFIED ANSWERS AND DETAILED RATIONALES
Question 1
A nurse is caring for a client with diabetic ketoacidosis. Which
laboratory finding requires immediate intervention?
A. Serum potassium 5.2 mEq/L
B. Serum glucose 350 mg/dL
C. Serum bicarbonate 10 mEq/L
D. Serum sodium 135 mEq/L
C. Serum bicarbonate 10 mEq/L
Rationale: A serum bicarbonate of 10 mEq/L indicates severe metabolic
acidosis and requires immediate intervention. The normal range is 22-
26 mEq/L. A glucose of 350 mg/dL is elevated but expected in DKA.
Potassium of 5.2 mEq/L is mildly elevated but may decrease with insulin
therapy. Sodium of 135 mEq/L is within normal limits.
Question 2
The nurse is administering IV potassium chloride to a client with
hypokalemia. Which action is most appropriate?
A. Administer via IV push over 5 minutes
B. Infuse at a rate of 20 mEq/hour through a peripheral IV
C. Dilute in 50 mL of normal saline and infuse over 30 minutes
D. Administer through a central line at 40 mEq/hour
,B. Infuse at a rate of 20 mEq/hour through a peripheral IV
Rationale: IV potassium should be infused at a maximum rate of 10-20
mEq/hour through a peripheral IV and never given via IV push. Central
lines may allow up to 40 mEq/hour but peripheral lines should not
exceed 20 mEq/hour. Potassium must be diluted and infused slowly to
prevent cardiac complications.
Question 3
A client with heart failure is prescribed furosemide. Which assessment
finding indicates the medication is effective?
A. Decreased blood pressure
B. Increased urine output
C. Weight gain of 2 kg
D. Crackles in lung bases
B. Increased urine output
Rationale: Furosemide is a loop diuretic used to reduce fluid volume in
heart failure. Increased urine output indicates effective diuresis.
Decreased blood pressure may be an adverse effect. Weight gain and
crackles indicate fluid retention and worsening heart failure.
Question 4
The nurse is caring for a client with acute respiratory distress syndrome
(ARDS). Which ventilator setting is most appropriate?
A. Tidal volume 10 mL/kg
B. Plateau pressure 35 cm H2O
C. PEEP 12 cm H2O
D. Respiratory rate 8 breaths/min
,C. PEEP 12 cm H2O
Rationale: ARDS management includes low tidal volume (6 mL/kg),
plateau pressure less than 30 cm H2O, and higher PEEP to recruit
alveoli. A PEEP of 12 cm H2O is appropriate. Tidal volume of 10 mL/kg is
too high and can cause lung injury. Plateau pressure of 35 cm H2O
exceeds the recommended limit.
Question 5
A postpartum client reports heavy bleeding with clots. The nurse
assesses a boggy uterus at the umbilicus. Which action should the nurse
take first?
A. Administer oxytocin as prescribed
B. Call the healthcare provider
C. Massage the uterine fundus
D. Prepare for blood transfusion
C. Massage the uterine fundus
Rationale: A boggy uterus indicates uterine atony, the most common
cause of postpartum hemorrhage. The priority action is to massage the
fundus to stimulate uterine contraction. Oxytocin should be
administered after massage if bleeding continues. The provider should
be notified but massage is the immediate intervention.
Question 6
The nurse is assessing a child with suspected appendicitis. Which
finding is most concerning?
A. Rebound tenderness in the right lower quadrant
B. Temperature of 99.8°F
, C. Nausea and vomiting
D. WBC count of 12,000/mm³
A. Rebound tenderness in the right lower quadrant
Rationale: Rebound tenderness in the right lower quadrant is a classic
sign of appendicitis and indicates peritoneal irritation. While fever,
nausea, vomiting, and elevated WBC are associated with appendicitis,
rebound tenderness is the most specific finding indicating possible
rupture.
Question 7
A client with major depressive disorder is prescribed phenelzine. Which
dietary instruction is most important?
A. Avoid foods containing tyramine
B. Limit caffeine intake
C. Increase fiber intake
D. Restrict sodium intake
A. Avoid foods containing tyramine
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Clients
must avoid tyramine-containing foods (aged cheese, cured meats,
fermented products) to prevent hypertensive crisis. This is the most
critical dietary instruction for client safety.
Question 8
The charge nurse is delegating tasks to unlicensed assistive personnel
(UAP). Which task is appropriate to delegate?
A. Administering oral medications
B. Inserting a Foley catheter
100% VERIFIED ANSWERS AND DETAILED RATIONALES
Question 1
A nurse is caring for a client with diabetic ketoacidosis. Which
laboratory finding requires immediate intervention?
A. Serum potassium 5.2 mEq/L
B. Serum glucose 350 mg/dL
C. Serum bicarbonate 10 mEq/L
D. Serum sodium 135 mEq/L
C. Serum bicarbonate 10 mEq/L
Rationale: A serum bicarbonate of 10 mEq/L indicates severe metabolic
acidosis and requires immediate intervention. The normal range is 22-
26 mEq/L. A glucose of 350 mg/dL is elevated but expected in DKA.
Potassium of 5.2 mEq/L is mildly elevated but may decrease with insulin
therapy. Sodium of 135 mEq/L is within normal limits.
Question 2
The nurse is administering IV potassium chloride to a client with
hypokalemia. Which action is most appropriate?
A. Administer via IV push over 5 minutes
B. Infuse at a rate of 20 mEq/hour through a peripheral IV
C. Dilute in 50 mL of normal saline and infuse over 30 minutes
D. Administer through a central line at 40 mEq/hour
,B. Infuse at a rate of 20 mEq/hour through a peripheral IV
Rationale: IV potassium should be infused at a maximum rate of 10-20
mEq/hour through a peripheral IV and never given via IV push. Central
lines may allow up to 40 mEq/hour but peripheral lines should not
exceed 20 mEq/hour. Potassium must be diluted and infused slowly to
prevent cardiac complications.
Question 3
A client with heart failure is prescribed furosemide. Which assessment
finding indicates the medication is effective?
A. Decreased blood pressure
B. Increased urine output
C. Weight gain of 2 kg
D. Crackles in lung bases
B. Increased urine output
Rationale: Furosemide is a loop diuretic used to reduce fluid volume in
heart failure. Increased urine output indicates effective diuresis.
Decreased blood pressure may be an adverse effect. Weight gain and
crackles indicate fluid retention and worsening heart failure.
Question 4
The nurse is caring for a client with acute respiratory distress syndrome
(ARDS). Which ventilator setting is most appropriate?
A. Tidal volume 10 mL/kg
B. Plateau pressure 35 cm H2O
C. PEEP 12 cm H2O
D. Respiratory rate 8 breaths/min
,C. PEEP 12 cm H2O
Rationale: ARDS management includes low tidal volume (6 mL/kg),
plateau pressure less than 30 cm H2O, and higher PEEP to recruit
alveoli. A PEEP of 12 cm H2O is appropriate. Tidal volume of 10 mL/kg is
too high and can cause lung injury. Plateau pressure of 35 cm H2O
exceeds the recommended limit.
Question 5
A postpartum client reports heavy bleeding with clots. The nurse
assesses a boggy uterus at the umbilicus. Which action should the nurse
take first?
A. Administer oxytocin as prescribed
B. Call the healthcare provider
C. Massage the uterine fundus
D. Prepare for blood transfusion
C. Massage the uterine fundus
Rationale: A boggy uterus indicates uterine atony, the most common
cause of postpartum hemorrhage. The priority action is to massage the
fundus to stimulate uterine contraction. Oxytocin should be
administered after massage if bleeding continues. The provider should
be notified but massage is the immediate intervention.
Question 6
The nurse is assessing a child with suspected appendicitis. Which
finding is most concerning?
A. Rebound tenderness in the right lower quadrant
B. Temperature of 99.8°F
, C. Nausea and vomiting
D. WBC count of 12,000/mm³
A. Rebound tenderness in the right lower quadrant
Rationale: Rebound tenderness in the right lower quadrant is a classic
sign of appendicitis and indicates peritoneal irritation. While fever,
nausea, vomiting, and elevated WBC are associated with appendicitis,
rebound tenderness is the most specific finding indicating possible
rupture.
Question 7
A client with major depressive disorder is prescribed phenelzine. Which
dietary instruction is most important?
A. Avoid foods containing tyramine
B. Limit caffeine intake
C. Increase fiber intake
D. Restrict sodium intake
A. Avoid foods containing tyramine
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Clients
must avoid tyramine-containing foods (aged cheese, cured meats,
fermented products) to prevent hypertensive crisis. This is the most
critical dietary instruction for client safety.
Question 8
The charge nurse is delegating tasks to unlicensed assistive personnel
(UAP). Which task is appropriate to delegate?
A. Administering oral medications
B. Inserting a Foley catheter
