NUR 2571 Final Exam Actual Exam V3 | NUR 2571 Professional
Nursing II / PN2 (NUR2571 Final Exam) | Rasmussen
1. A nurse is caring for a patient in the ICU who is being treated for Septic Shock. Which
assessment finding most clearly indicates that the patient is progressing toward Multiple
Organ Dysfunction Syndrome (MODS)?
A. A serum lactate level of 2.2 mmol/L.
B. Mean Arterial Pressure (MAP) of 70 mmHg.
C. Decreased urine output to less than 30 mL/hr despite fluid resuscitation.
D. A white blood cell count of 12,000/mm3.
Answer: C
Rationale: Decreased urine output despite adequate fluid resuscitation suggests acute
kidney injury, which is a common early indicator of MODS. In the context of septic shock,
the failure of one organ system often leads to others. This finding requires immediate
notification of the provider to prevent irreversible damage.
2. A patient with Chronic Kidney Disease (CKD) presents with a potassium level of 6.8 mEq/L.
Which of the following provider orders should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Administer regular insulin and 50% Dextrose intravenously.
C. Initiate a low-potassium diet.
D. Administer 10% Calcium Gluconate intravenously.
Answer: D
Rationale: Calcium gluconate is administered first to stabilize the myocardial cell
membrane and prevent life-threatening arrhythmias associated with severe hyperkalemia.
While insulin/dextrose shifts potassium into cells and Kayexalate removes it from the
body, they do not provide immediate cardiac protection. This sequence is vital for patient
safety in emergency electrolyte management.
3. The nurse is monitoring a patient on mechanical ventilation. The high-pressure alarm
sounds. Which of the following is the most appropriate initial action by the nurse?
A. Increase the oxygen concentration on the ventilator settings.
B. Silence the alarm and wait to see if it recurs.
C. Disconnect the patient from the ventilator and use a bag-valve mask.
D. Assess the patient’s breath sounds and check for secretions.
,Answer: D
Rationale: High-pressure alarms are typically triggered by increased resistance, such as
secretions, coughing, or the patient biting the ETT tube. Assessing the patient first ensures
the cause is identified quickly and potentially resolved via suctioning. If the patient is in
distress and the cause is not found, then manual ventilation would be the next step.
4. A patient is admitted with a suspected Acute Myocardial Infarction (AMI). Which diagnostic
finding is most specific for myocardial injury?
A. Elevated Creatine Kinase (CK-MB).
B. Elevated Troponin I.
C. Presence of ST-segment depression.
D. Sinus Tachycardia on the EKG.
Answer: B
Rationale: Troponin I is a highly specific cardiac marker that rises within hours of
myocardial damage and stays elevated for days. While CK-MB is also used, it is less specific
than Troponin I for cardiac tissue. ST-segment depression indicates ischemia rather than
definitive injury, and tachycardia is non-specific.
5. A patient with a history of heart failure reports a weight gain of 5 lbs in 2 days and
increased shortness of breath. Which assessment should the nurse perform next?
A. Assess for peripheral edema in the lower extremities.
B. Review the patient’s most recent BNP level.
C. Check the patient’s blood pressure.
D. Auscultate the lungs for crackles.
Answer: D
Rationale: Shortness of breath and rapid weight gain in a heart failure patient often
indicate pulmonary edema or fluid volume overload. Auscultating lung sounds for crackles
is the priority to assess for left-sided heart failure complications. This immediate physical
assessment guides the need for diuretic therapy or oxygen intervention.
6. A nurse is caring for a patient who just returned from a kidney transplant. Which finding is
the most concerning and requires immediate notification of the surgeon?
A. Tenderness at the incision site.
B. Urine output of 20 mL over the last hour.
C. Serum creatinine of 1.4 mg/dL.
D. A temperature of 99.2 F (37.3 C).
, Answer: B
Rationale: Sudden or significant decrease in urine output post-transplant may indicate
rejection, thrombosis of the renal artery, or obstruction. Post-operative kidney patients are
expected to have high urine output initially due to the osmotic diuresis. Failure to report
low output can lead to loss of the new organ.
7. A patient is admitted with Diabetic Ketoacidosis (DKA). The nurse should expect to find
which of the following arterial blood gas (ABG) results?
A. pH 7.50, PaCO2 35, HCO3 30
B. pH 7.30, PaCO2 30, HCO3 15
C. pH 7.32, PaCO2 50, HCO3 26
D. pH 7.48, PaCO2 25, HCO3 22
Answer: B
Rationale: DKA is characterized by metabolic acidosis due to the accumulation of ketones.
A pH of 7.30 (acidic) with a low bicarbonate (15) confirms metabolic acidosis, while the
low PaCO2 (30) shows the body’s respiratory compensation through Kussmaul
respirations. This pattern is classic for uncontrolled hyperglycemia in Type 1 diabetics.
8. A nurse is managing a patient with increased intracranial pressure (ICP). Which of the
following nursing interventions is appropriate?
A. Maintain the head of the bed at 30 to 45 degrees.
B. Group all nursing activities together to allow for long rest periods.
C. Encourage the patient to perform the Valsalva maneuver during repositioning.
D. Suction the patient hourly to maintain airway patency.
Answer: A
Rationale: Elevating the head of the bed promotes venous drainage from the head, which
helps decrease ICP. In contrast, grouping activities or suctioning can actually trigger spikes
in ICP, and the Valsalva maneuver significantly increases thoracic and intracranial
pressure. These interventions must be carefully controlled to prevent herniation.
9. During the emergent phase of a burn injury, the nurse should prioritize assessment for
which of the following electrolyte imbalances?
A. Hypokalemia and Hyponatremia.
B. Hypercalcemia and Hypermagnesemia.
C. Hyperkalemia and Hyponatremia.
D. Hypokalemia and Hypernatremia.
Nursing II / PN2 (NUR2571 Final Exam) | Rasmussen
1. A nurse is caring for a patient in the ICU who is being treated for Septic Shock. Which
assessment finding most clearly indicates that the patient is progressing toward Multiple
Organ Dysfunction Syndrome (MODS)?
A. A serum lactate level of 2.2 mmol/L.
B. Mean Arterial Pressure (MAP) of 70 mmHg.
C. Decreased urine output to less than 30 mL/hr despite fluid resuscitation.
D. A white blood cell count of 12,000/mm3.
Answer: C
Rationale: Decreased urine output despite adequate fluid resuscitation suggests acute
kidney injury, which is a common early indicator of MODS. In the context of septic shock,
the failure of one organ system often leads to others. This finding requires immediate
notification of the provider to prevent irreversible damage.
2. A patient with Chronic Kidney Disease (CKD) presents with a potassium level of 6.8 mEq/L.
Which of the following provider orders should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Administer regular insulin and 50% Dextrose intravenously.
C. Initiate a low-potassium diet.
D. Administer 10% Calcium Gluconate intravenously.
Answer: D
Rationale: Calcium gluconate is administered first to stabilize the myocardial cell
membrane and prevent life-threatening arrhythmias associated with severe hyperkalemia.
While insulin/dextrose shifts potassium into cells and Kayexalate removes it from the
body, they do not provide immediate cardiac protection. This sequence is vital for patient
safety in emergency electrolyte management.
3. The nurse is monitoring a patient on mechanical ventilation. The high-pressure alarm
sounds. Which of the following is the most appropriate initial action by the nurse?
A. Increase the oxygen concentration on the ventilator settings.
B. Silence the alarm and wait to see if it recurs.
C. Disconnect the patient from the ventilator and use a bag-valve mask.
D. Assess the patient’s breath sounds and check for secretions.
,Answer: D
Rationale: High-pressure alarms are typically triggered by increased resistance, such as
secretions, coughing, or the patient biting the ETT tube. Assessing the patient first ensures
the cause is identified quickly and potentially resolved via suctioning. If the patient is in
distress and the cause is not found, then manual ventilation would be the next step.
4. A patient is admitted with a suspected Acute Myocardial Infarction (AMI). Which diagnostic
finding is most specific for myocardial injury?
A. Elevated Creatine Kinase (CK-MB).
B. Elevated Troponin I.
C. Presence of ST-segment depression.
D. Sinus Tachycardia on the EKG.
Answer: B
Rationale: Troponin I is a highly specific cardiac marker that rises within hours of
myocardial damage and stays elevated for days. While CK-MB is also used, it is less specific
than Troponin I for cardiac tissue. ST-segment depression indicates ischemia rather than
definitive injury, and tachycardia is non-specific.
5. A patient with a history of heart failure reports a weight gain of 5 lbs in 2 days and
increased shortness of breath. Which assessment should the nurse perform next?
A. Assess for peripheral edema in the lower extremities.
B. Review the patient’s most recent BNP level.
C. Check the patient’s blood pressure.
D. Auscultate the lungs for crackles.
Answer: D
Rationale: Shortness of breath and rapid weight gain in a heart failure patient often
indicate pulmonary edema or fluid volume overload. Auscultating lung sounds for crackles
is the priority to assess for left-sided heart failure complications. This immediate physical
assessment guides the need for diuretic therapy or oxygen intervention.
6. A nurse is caring for a patient who just returned from a kidney transplant. Which finding is
the most concerning and requires immediate notification of the surgeon?
A. Tenderness at the incision site.
B. Urine output of 20 mL over the last hour.
C. Serum creatinine of 1.4 mg/dL.
D. A temperature of 99.2 F (37.3 C).
, Answer: B
Rationale: Sudden or significant decrease in urine output post-transplant may indicate
rejection, thrombosis of the renal artery, or obstruction. Post-operative kidney patients are
expected to have high urine output initially due to the osmotic diuresis. Failure to report
low output can lead to loss of the new organ.
7. A patient is admitted with Diabetic Ketoacidosis (DKA). The nurse should expect to find
which of the following arterial blood gas (ABG) results?
A. pH 7.50, PaCO2 35, HCO3 30
B. pH 7.30, PaCO2 30, HCO3 15
C. pH 7.32, PaCO2 50, HCO3 26
D. pH 7.48, PaCO2 25, HCO3 22
Answer: B
Rationale: DKA is characterized by metabolic acidosis due to the accumulation of ketones.
A pH of 7.30 (acidic) with a low bicarbonate (15) confirms metabolic acidosis, while the
low PaCO2 (30) shows the body’s respiratory compensation through Kussmaul
respirations. This pattern is classic for uncontrolled hyperglycemia in Type 1 diabetics.
8. A nurse is managing a patient with increased intracranial pressure (ICP). Which of the
following nursing interventions is appropriate?
A. Maintain the head of the bed at 30 to 45 degrees.
B. Group all nursing activities together to allow for long rest periods.
C. Encourage the patient to perform the Valsalva maneuver during repositioning.
D. Suction the patient hourly to maintain airway patency.
Answer: A
Rationale: Elevating the head of the bed promotes venous drainage from the head, which
helps decrease ICP. In contrast, grouping activities or suctioning can actually trigger spikes
in ICP, and the Valsalva maneuver significantly increases thoracic and intracranial
pressure. These interventions must be carefully controlled to prevent herniation.
9. During the emergent phase of a burn injury, the nurse should prioritize assessment for
which of the following electrolyte imbalances?
A. Hypokalemia and Hyponatremia.
B. Hypercalcemia and Hypermagnesemia.
C. Hyperkalemia and Hyponatremia.
D. Hypokalemia and Hypernatremia.
