NUR 2571 Exam 3 Actual Exam V2 | NUR 2571 Professional Nursing II /
PN2 (NUR2571 Exam 3) | Rasmussen
1. A client with an absolute neutrophil count (ANC) of 400/mm³ is admitted to the oncology
unit. Which nursing intervention is the priority?
A. Placing the client in a private room with reverse isolation.
B. Administering the prescribed prophylactic antibiotic.
C. Assessing the client’s temperature every 4 hours.
D. Providing the client with a low-bacteria diet.
Answer: A
Rationale: An ANC below 500/mm³ indicates severe neutropenia and a high risk for life-
threatening infection. The priority action is to create a protective environment to minimize
the client’s exposure to exogenous pathogens. While monitoring temperature and
administering medications are important, environmental control through reverse isolation
is a foundational safety measure in these cases.
2. A nurse is caring for a client experiencing Superior Vena Cava Syndrome (SVCS). Which
assessment finding should the nurse anticipate?
A. Severe hypotension and bradycardia.
B. Numbness and tingling in the lower extremities.
C. Periorbital edema and facial swelling.
D. Acute flank pain and hematuria.
Answer: C
Rationale: SVCS occurs when the superior vena cava is compressed, usually by a tumor,
leading to obstructed blood flow from the head and neck. Classic signs include periorbital
and facial edema, jugular vein distention, and shortness of breath. This is considered an
oncologic emergency requiring immediate intervention to relieve pressure.
3. A client diagnosed with HIV has a CD4+ T-cell count of 180 cells/mm³. How should the
nurse interpret this finding?
A. The client is in the acute infection stage of HIV.
B. The client’s immune system is currently stable.
C. The client has progressed to the AIDS stage.
D. The client is at risk for a transfusion reaction.
,Answer: C
Rationale: A CD4+ T-cell count below 200 cells/mm³ is one of the clinical definitions used
to diagnose the progression from HIV to AIDS. At this stage, the client is severely
immunocompromised and highly susceptible to opportunistic infections. The nurse must
focus on infection prevention and monitoring for AIDS-defining illnesses.
4. A client is receiving external beam radiation for lung cancer. Which instruction should the
nurse include in the skin care teaching?
A. Apply a heating pad to the site if pain occurs.
B. Scrub the radiation markings daily with a washcloth.
C. Apply over-the-counter lotion to keep the skin moist.
D. Use only lukewarm water and mild soap on the area.
Answer: D
Rationale: Radiation skin reactions range from redness to desquamation, and the skin in
the treatment field is extremely fragile. Clients should avoid extreme temperatures,
scrubbing, or applying non-prescribed lotions that may contain metals or irritants. Gentle
cleansing with lukewarm water and mild soap helps maintain skin integrity without
causing further damage.
5. Which laboratory result is most indicative of Disseminated Intravascular Coagulation (DIC)?
A. Increased fibrinogen levels.
B. Decreased Prothrombin Time (PT).
C. Increased D-dimer levels.
D. Increased platelet count.
Answer: C
Rationale: DIC is characterized by systemic activation of blood coagulation, which leads to
the consumption of clotting factors and platelets. D-dimer is a fibrin degradation product;
its elevation indicates significant clot breakdown within the body. Other markers include
prolonged PT/PTT and decreased fibrinogen and platelets.
6. A client with sickle cell anemia is admitted in a vaso-occlusive crisis. What is the priority
nursing goal?
A. Administering broad-spectrum antibiotics.
B. Encouraging a high-protein diet.
C. Providing adequate pain management and hydration.
D. Implementing strict bed rest with no movement.
, Answer: C
Rationale: In a vaso-occlusive crisis, sickled cells obstruct blood flow, causing tissue
hypoxia and severe pain. Hydration is critical to decrease blood viscosity, while aggressive
pain management is necessary for comfort. Together, these interventions address the
physiological stress and the primary symptoms of the crisis.
7. A client receiving chemotherapy developed stomatitis. Which intervention should the
nurse suggest?
A. Rinse the mouth with an alcohol-based mouthwash.
B. Use a firm-bristle toothbrush to remove plaque.
C. Rinse the mouth with a salt and soda solution.
D. Eat spicy foods to stimulate taste buds.
Answer: C
Rationale: Stomatitis is an inflammation of the oral mucosa that can lead to painful
ulcerations. A salt and baking soda rinse is non-irritating and helps maintain a neutral pH
in the mouth. Clients should avoid alcohol-based products and spicy or acidic foods, which
can further damage the sensitive tissue.
8. During a blood transfusion, the client reports chills, low back pain, and nausea. What is the
nurse’s first action?
A. Slow the infusion rate and notify the provider.
B. Stop the transfusion immediately.
C. Administer diphenhydramine as ordered.
D. Check the client’s vital signs and continue monitoring.
Answer: B
Rationale: Low back pain, chills, and nausea are classic signs of an acute hemolytic
transfusion reaction. The first and most critical step is to stop the transfusion to prevent
further exposure to incompatible blood. After stopping the infusion, the nurse should
maintain the IV line with normal saline and notify the physician and blood bank.
9. A nurse is teaching a client about the prevention of Lymphedema after a right-sided
mastectomy. Which statement by the client indicates a need for further teaching?
A. I should wear a compression sleeve when I fly.
B. I will ask for blood draws to be done on my left arm only.
C. I should use an electric razor for shaving under my right arm.
D. It’s okay to have my blood pressure taken on my right arm.
PN2 (NUR2571 Exam 3) | Rasmussen
1. A client with an absolute neutrophil count (ANC) of 400/mm³ is admitted to the oncology
unit. Which nursing intervention is the priority?
A. Placing the client in a private room with reverse isolation.
B. Administering the prescribed prophylactic antibiotic.
C. Assessing the client’s temperature every 4 hours.
D. Providing the client with a low-bacteria diet.
Answer: A
Rationale: An ANC below 500/mm³ indicates severe neutropenia and a high risk for life-
threatening infection. The priority action is to create a protective environment to minimize
the client’s exposure to exogenous pathogens. While monitoring temperature and
administering medications are important, environmental control through reverse isolation
is a foundational safety measure in these cases.
2. A nurse is caring for a client experiencing Superior Vena Cava Syndrome (SVCS). Which
assessment finding should the nurse anticipate?
A. Severe hypotension and bradycardia.
B. Numbness and tingling in the lower extremities.
C. Periorbital edema and facial swelling.
D. Acute flank pain and hematuria.
Answer: C
Rationale: SVCS occurs when the superior vena cava is compressed, usually by a tumor,
leading to obstructed blood flow from the head and neck. Classic signs include periorbital
and facial edema, jugular vein distention, and shortness of breath. This is considered an
oncologic emergency requiring immediate intervention to relieve pressure.
3. A client diagnosed with HIV has a CD4+ T-cell count of 180 cells/mm³. How should the
nurse interpret this finding?
A. The client is in the acute infection stage of HIV.
B. The client’s immune system is currently stable.
C. The client has progressed to the AIDS stage.
D. The client is at risk for a transfusion reaction.
,Answer: C
Rationale: A CD4+ T-cell count below 200 cells/mm³ is one of the clinical definitions used
to diagnose the progression from HIV to AIDS. At this stage, the client is severely
immunocompromised and highly susceptible to opportunistic infections. The nurse must
focus on infection prevention and monitoring for AIDS-defining illnesses.
4. A client is receiving external beam radiation for lung cancer. Which instruction should the
nurse include in the skin care teaching?
A. Apply a heating pad to the site if pain occurs.
B. Scrub the radiation markings daily with a washcloth.
C. Apply over-the-counter lotion to keep the skin moist.
D. Use only lukewarm water and mild soap on the area.
Answer: D
Rationale: Radiation skin reactions range from redness to desquamation, and the skin in
the treatment field is extremely fragile. Clients should avoid extreme temperatures,
scrubbing, or applying non-prescribed lotions that may contain metals or irritants. Gentle
cleansing with lukewarm water and mild soap helps maintain skin integrity without
causing further damage.
5. Which laboratory result is most indicative of Disseminated Intravascular Coagulation (DIC)?
A. Increased fibrinogen levels.
B. Decreased Prothrombin Time (PT).
C. Increased D-dimer levels.
D. Increased platelet count.
Answer: C
Rationale: DIC is characterized by systemic activation of blood coagulation, which leads to
the consumption of clotting factors and platelets. D-dimer is a fibrin degradation product;
its elevation indicates significant clot breakdown within the body. Other markers include
prolonged PT/PTT and decreased fibrinogen and platelets.
6. A client with sickle cell anemia is admitted in a vaso-occlusive crisis. What is the priority
nursing goal?
A. Administering broad-spectrum antibiotics.
B. Encouraging a high-protein diet.
C. Providing adequate pain management and hydration.
D. Implementing strict bed rest with no movement.
, Answer: C
Rationale: In a vaso-occlusive crisis, sickled cells obstruct blood flow, causing tissue
hypoxia and severe pain. Hydration is critical to decrease blood viscosity, while aggressive
pain management is necessary for comfort. Together, these interventions address the
physiological stress and the primary symptoms of the crisis.
7. A client receiving chemotherapy developed stomatitis. Which intervention should the
nurse suggest?
A. Rinse the mouth with an alcohol-based mouthwash.
B. Use a firm-bristle toothbrush to remove plaque.
C. Rinse the mouth with a salt and soda solution.
D. Eat spicy foods to stimulate taste buds.
Answer: C
Rationale: Stomatitis is an inflammation of the oral mucosa that can lead to painful
ulcerations. A salt and baking soda rinse is non-irritating and helps maintain a neutral pH
in the mouth. Clients should avoid alcohol-based products and spicy or acidic foods, which
can further damage the sensitive tissue.
8. During a blood transfusion, the client reports chills, low back pain, and nausea. What is the
nurse’s first action?
A. Slow the infusion rate and notify the provider.
B. Stop the transfusion immediately.
C. Administer diphenhydramine as ordered.
D. Check the client’s vital signs and continue monitoring.
Answer: B
Rationale: Low back pain, chills, and nausea are classic signs of an acute hemolytic
transfusion reaction. The first and most critical step is to stop the transfusion to prevent
further exposure to incompatible blood. After stopping the infusion, the nurse should
maintain the IV line with normal saline and notify the physician and blood bank.
9. A nurse is teaching a client about the prevention of Lymphedema after a right-sided
mastectomy. Which statement by the client indicates a need for further teaching?
A. I should wear a compression sleeve when I fly.
B. I will ask for blood draws to be done on my left arm only.
C. I should use an electric razor for shaving under my right arm.
D. It’s okay to have my blood pressure taken on my right arm.
