NUR 231 FINAL EXAM – ADULT
NURSING II QUESTIONS & VERIFIED
ANSWERS | ILLINOIS STATE
UNIVERSITY (A+ GUARANTEE)
1. A patient with left-sided heart failure is admitted to the medical-surgical unit. Which
clinical manifestation should the nurse expect to find during the assessment?
A. Jugular venous distension
B. Crackles and wheezes in the lungs
C. Splenomegaly and hepatomegaly
D. Dependent peripheral edema
Answer: B
Conceptual Explanation: Left-sided heart failure causes blood to back up into the
pulmonary veins, leading to pulmonary congestion and symptoms like crackles and
wheezes. Options A, B, and D are signs of right-sided heart failure.
2. When interpreting an arterial blood gas (ABG) for a patient with COPD, the nurse notes: pH
7.32, PaCO2 58 mmHg, and HCO3 30 mEq/L. How should the nurse interpret these results?
A. Respiratory acidosis, partially compensated
B. Metabolic acidosis, fully compensated
,C. Respiratory alkalosis, uncompensated
D. Metabolic alkalosis, partially compensated
Answer: A
Conceptual Explanation: The pH is acidic (<7.35), the PaCO2 is high (>45), and the HCO3
is high (>26). The elevated HCO3 indicates the kidneys are trying to compensate for the
primary respiratory acidosis.
3. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome (ARDS).
Which ventilator setting should the nurse anticipate to improve oxygenation and keep alveoli
open?
A. Low Positive End-Expiratory Pressure (PEEP)
B. High Fraction of Inspired Oxygen (FiO2) alone
C. Increased Positive End-Expiratory Pressure (PEEP)
D. Decreased Tidal Volume without PEEP
Answer: C
Conceptual Explanation: PEEP is used in ARDS to prevent alveolar collapse at the end of
expiration, thereby improving gas exchange and oxygenation.
4. During a cardiac arrest, the monitor shows ventricular fibrillation (VF). What is the priority
nursing action?
A. Perform immediate defibrillation
, B. Administer IV Epinephrine 1mg
C. Start synchronized cardioversion
D. Administer IV Amiodarone 300mg
Answer: A
Conceptual Explanation: Defibrillation is the treatment of choice for VF and pulseless
ventricular tachycardia. It should be performed as soon as a defibrillator is available.
5. A patient with a history of Chronic Kidney Disease (CKD) presents with a potassium level of
6.8 mEq/L and tall, peaked T-waves on the ECG. Which medication should the nurse expect to
administer first to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular Insulin and D50
D. Calcium Gluconate
Answer: D
Conceptual Explanation: Calcium gluconate does not lower potassium but is administered
first in severe hyperkalemia to stabilize the myocardium and prevent lethal dysrhythmias.
6. Which clinical finding is part of Cushing’s Triad, indicating increased intracranial pressure
(ICP)?
A. Tachycardia, hypotension, and tachypnea
NURSING II QUESTIONS & VERIFIED
ANSWERS | ILLINOIS STATE
UNIVERSITY (A+ GUARANTEE)
1. A patient with left-sided heart failure is admitted to the medical-surgical unit. Which
clinical manifestation should the nurse expect to find during the assessment?
A. Jugular venous distension
B. Crackles and wheezes in the lungs
C. Splenomegaly and hepatomegaly
D. Dependent peripheral edema
Answer: B
Conceptual Explanation: Left-sided heart failure causes blood to back up into the
pulmonary veins, leading to pulmonary congestion and symptoms like crackles and
wheezes. Options A, B, and D are signs of right-sided heart failure.
2. When interpreting an arterial blood gas (ABG) for a patient with COPD, the nurse notes: pH
7.32, PaCO2 58 mmHg, and HCO3 30 mEq/L. How should the nurse interpret these results?
A. Respiratory acidosis, partially compensated
B. Metabolic acidosis, fully compensated
,C. Respiratory alkalosis, uncompensated
D. Metabolic alkalosis, partially compensated
Answer: A
Conceptual Explanation: The pH is acidic (<7.35), the PaCO2 is high (>45), and the HCO3
is high (>26). The elevated HCO3 indicates the kidneys are trying to compensate for the
primary respiratory acidosis.
3. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome (ARDS).
Which ventilator setting should the nurse anticipate to improve oxygenation and keep alveoli
open?
A. Low Positive End-Expiratory Pressure (PEEP)
B. High Fraction of Inspired Oxygen (FiO2) alone
C. Increased Positive End-Expiratory Pressure (PEEP)
D. Decreased Tidal Volume without PEEP
Answer: C
Conceptual Explanation: PEEP is used in ARDS to prevent alveolar collapse at the end of
expiration, thereby improving gas exchange and oxygenation.
4. During a cardiac arrest, the monitor shows ventricular fibrillation (VF). What is the priority
nursing action?
A. Perform immediate defibrillation
, B. Administer IV Epinephrine 1mg
C. Start synchronized cardioversion
D. Administer IV Amiodarone 300mg
Answer: A
Conceptual Explanation: Defibrillation is the treatment of choice for VF and pulseless
ventricular tachycardia. It should be performed as soon as a defibrillator is available.
5. A patient with a history of Chronic Kidney Disease (CKD) presents with a potassium level of
6.8 mEq/L and tall, peaked T-waves on the ECG. Which medication should the nurse expect to
administer first to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular Insulin and D50
D. Calcium Gluconate
Answer: D
Conceptual Explanation: Calcium gluconate does not lower potassium but is administered
first in severe hyperkalemia to stabilize the myocardium and prevent lethal dysrhythmias.
6. Which clinical finding is part of Cushing’s Triad, indicating increased intracranial pressure
(ICP)?
A. Tachycardia, hypotension, and tachypnea
