NUR 2571 Exam 2 Actual Exam V3 | NUR 2571 Professional Nursing II /
PN2 (NUR2571 Exam 2) | Rasmussen
1. A patient with acute decompensated heart failure is admitted. The patient has 3+ pitting
edema in the lower extremities and crackles in the lungs. Which intervention should the
nurse perform first?
A. Obtain a daily weight.
B. Administer 40 mg IV furosemide as ordered.
C. Educate the patient on a low-sodium diet.
D. Elevate the head of the bed and apply oxygen.
Answer: D
Rationale: In an acute heart failure exacerbation, the priority is maintaining adequate
oxygenation and reducing respiratory effort. Elevating the head of the bed decreases
venous return and allows for better lung expansion. While furosemide is vital for diuresis,
immediate physiological stabilization through positioning and oxygen takes precedence in
the ABC (Airway, Breathing, Circulation) framework.
2. A patient’s Arterial Blood Gas (ABG) results show: pH 7.30, PaCO2 52, HCO3 26. How
should the nurse interpret these findings?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The pH level is below 7.35, indicating acidosis, and the PaCO2 is elevated above
45, which correlates with the acidic pH. Since the bicarbonate (HCO3) is within the normal
range of 22-26, there is no compensation occurring yet. This clinical picture is consistent
with uncompensated respiratory acidosis, often caused by hypoventilation or COPD.
3. A nurse is monitoring a patient receiving digoxin for heart failure. Which finding would
most likely indicate digoxin toxicity?
A. Increased urine output
B. Visual disturbances, such as seeing yellow halos
C. Blood pressure of 140/90 mmHg
D. Heart rate of 88 beats per minute
,Answer: B
Rationale: Visual disturbances like blurred vision or yellow-green halos are classic signs of
digoxin toxicity. Other common signs include gastrointestinal distress such as nausea,
vomiting, and anorexia. The nurse must also monitor for bradycardia, as digoxin slows the
heart rate, and report these findings to the provider immediately.
4. A patient with Type 1 Diabetes presents to the emergency department with fruity breath,
Kussmaul respirations, and a blood glucose of 450 mg/dL. What is the nurse’s priority action?
A. Administer 10 units of regular insulin IV push.
B. Start a rapid infusion of 0.9% normal saline.
C. Administer 50% dextrose to prevent hypoglycemia.
D. Assess the patient’s potassium level.
Answer: B
Rationale: In Diabetic Ketoacidosis (DKA), the priority is fluid resuscitation to address
severe dehydration and restore circulatory volume. Once fluids are initiated, insulin
therapy can be started to lower blood glucose and stop ketone production. Monitoring
potassium is also vital because insulin will drive potassium into the cells, potentially
causing hypokalemia, but hydration remains the first step.
5. A nurse is caring for a postoperative patient who suddenly develops sharp chest pain and
shortness of breath. The patient’s heart rate is 110 bpm and SpO2 is 89%. Which condition
should the nurse suspect?
A. Pneumonia
B. Myocardial Infarction
C. Pneumothorax
D. Pulmonary Embolism
Answer: D
Rationale: The sudden onset of chest pain and dyspnea in a postoperative patient is a
hallmark sign of a pulmonary embolism (PE). Tachycardia and hypoxemia further support
this suspicion as the body attempts to compensate for a blockage in pulmonary blood flow.
Immediate notification of the Rapid Response Team and administration of oxygen are
required.
6. A patient is prescribed furosemide for the management of hypertension and fluid volume
excess. Which electrolyte imbalance should the nurse monitor for most closely?
A. Hyperkalemia
B. Hypernatremia
, C. Hypokalemia
D. Hypocalcemia
Answer: C
Rationale: Furosemide is a loop diuretic that causes the excretion of water, sodium, and
potassium. Hypokalemia is a significant risk and can lead to dangerous cardiac
dysrhythmias. Nurses should encourage the intake of potassium-rich foods or administer
supplements as prescribed to maintain levels within the 3.5 to 5.0 mEq/L range.
7. Which clinical manifestation would the nurse expect to find in a patient with
hypernatremia?
A. Polyuria and lightheadedness
B. Muscle tremors and hyperactive reflexes
C. Extreme thirst and dry mucous membranes
D. Bradycardia and hypotension
Answer: C
Rationale: Hypernatremia involves a high concentration of sodium in the blood, often due
to water loss, leading to cellular dehydration. Thirst is the body’s primary defense
mechanism against increased osmolarity. The nurse should also look for signs of neurologic
dysfunction, such as agitation or confusion, as brain cells shrink.
8. A patient with COPD is receiving oxygen therapy. Why is it important for the nurse to avoid
high concentrations of oxygen in this patient?
A. It may suppress the patient’s hypoxic drive to breathe.
B. It may cause excessive drying of the nasal mucosa.
C. High O2 levels can damage the alveoli permanently.
D. It increases the risk of oxygen toxicity in all patients.
Answer: A
Rationale: Patients with chronic hypercapnia (high CO2) often rely on a low oxygen level
(hypoxic drive) to stimulate breathing. Administering too much oxygen can increase PaO2
to a level that signals the brain to stop breathing. The nurse should aim for an SpO2 range
of 88-92% for most chronic COPD patients to maintain safety.
9. A patient is experiencing an acute asthma attack. Which medication should the nurse
administer first?
A. Methylprednisolone IV
B. Salmeterol inhaler
PN2 (NUR2571 Exam 2) | Rasmussen
1. A patient with acute decompensated heart failure is admitted. The patient has 3+ pitting
edema in the lower extremities and crackles in the lungs. Which intervention should the
nurse perform first?
A. Obtain a daily weight.
B. Administer 40 mg IV furosemide as ordered.
C. Educate the patient on a low-sodium diet.
D. Elevate the head of the bed and apply oxygen.
Answer: D
Rationale: In an acute heart failure exacerbation, the priority is maintaining adequate
oxygenation and reducing respiratory effort. Elevating the head of the bed decreases
venous return and allows for better lung expansion. While furosemide is vital for diuresis,
immediate physiological stabilization through positioning and oxygen takes precedence in
the ABC (Airway, Breathing, Circulation) framework.
2. A patient’s Arterial Blood Gas (ABG) results show: pH 7.30, PaCO2 52, HCO3 26. How
should the nurse interpret these findings?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The pH level is below 7.35, indicating acidosis, and the PaCO2 is elevated above
45, which correlates with the acidic pH. Since the bicarbonate (HCO3) is within the normal
range of 22-26, there is no compensation occurring yet. This clinical picture is consistent
with uncompensated respiratory acidosis, often caused by hypoventilation or COPD.
3. A nurse is monitoring a patient receiving digoxin for heart failure. Which finding would
most likely indicate digoxin toxicity?
A. Increased urine output
B. Visual disturbances, such as seeing yellow halos
C. Blood pressure of 140/90 mmHg
D. Heart rate of 88 beats per minute
,Answer: B
Rationale: Visual disturbances like blurred vision or yellow-green halos are classic signs of
digoxin toxicity. Other common signs include gastrointestinal distress such as nausea,
vomiting, and anorexia. The nurse must also monitor for bradycardia, as digoxin slows the
heart rate, and report these findings to the provider immediately.
4. A patient with Type 1 Diabetes presents to the emergency department with fruity breath,
Kussmaul respirations, and a blood glucose of 450 mg/dL. What is the nurse’s priority action?
A. Administer 10 units of regular insulin IV push.
B. Start a rapid infusion of 0.9% normal saline.
C. Administer 50% dextrose to prevent hypoglycemia.
D. Assess the patient’s potassium level.
Answer: B
Rationale: In Diabetic Ketoacidosis (DKA), the priority is fluid resuscitation to address
severe dehydration and restore circulatory volume. Once fluids are initiated, insulin
therapy can be started to lower blood glucose and stop ketone production. Monitoring
potassium is also vital because insulin will drive potassium into the cells, potentially
causing hypokalemia, but hydration remains the first step.
5. A nurse is caring for a postoperative patient who suddenly develops sharp chest pain and
shortness of breath. The patient’s heart rate is 110 bpm and SpO2 is 89%. Which condition
should the nurse suspect?
A. Pneumonia
B. Myocardial Infarction
C. Pneumothorax
D. Pulmonary Embolism
Answer: D
Rationale: The sudden onset of chest pain and dyspnea in a postoperative patient is a
hallmark sign of a pulmonary embolism (PE). Tachycardia and hypoxemia further support
this suspicion as the body attempts to compensate for a blockage in pulmonary blood flow.
Immediate notification of the Rapid Response Team and administration of oxygen are
required.
6. A patient is prescribed furosemide for the management of hypertension and fluid volume
excess. Which electrolyte imbalance should the nurse monitor for most closely?
A. Hyperkalemia
B. Hypernatremia
, C. Hypokalemia
D. Hypocalcemia
Answer: C
Rationale: Furosemide is a loop diuretic that causes the excretion of water, sodium, and
potassium. Hypokalemia is a significant risk and can lead to dangerous cardiac
dysrhythmias. Nurses should encourage the intake of potassium-rich foods or administer
supplements as prescribed to maintain levels within the 3.5 to 5.0 mEq/L range.
7. Which clinical manifestation would the nurse expect to find in a patient with
hypernatremia?
A. Polyuria and lightheadedness
B. Muscle tremors and hyperactive reflexes
C. Extreme thirst and dry mucous membranes
D. Bradycardia and hypotension
Answer: C
Rationale: Hypernatremia involves a high concentration of sodium in the blood, often due
to water loss, leading to cellular dehydration. Thirst is the body’s primary defense
mechanism against increased osmolarity. The nurse should also look for signs of neurologic
dysfunction, such as agitation or confusion, as brain cells shrink.
8. A patient with COPD is receiving oxygen therapy. Why is it important for the nurse to avoid
high concentrations of oxygen in this patient?
A. It may suppress the patient’s hypoxic drive to breathe.
B. It may cause excessive drying of the nasal mucosa.
C. High O2 levels can damage the alveoli permanently.
D. It increases the risk of oxygen toxicity in all patients.
Answer: A
Rationale: Patients with chronic hypercapnia (high CO2) often rely on a low oxygen level
(hypoxic drive) to stimulate breathing. Administering too much oxygen can increase PaO2
to a level that signals the brain to stop breathing. The nurse should aim for an SpO2 range
of 88-92% for most chronic COPD patients to maintain safety.
9. A patient is experiencing an acute asthma attack. Which medication should the nurse
administer first?
A. Methylprednisolone IV
B. Salmeterol inhaler
