NUR 2571 Final Exam Actual Exam V2 | NUR 2571 Professional
Nursing II / PN2 (NUR2571 Final Exam) | Rasmussen
1. A nurse is caring for a patient who is 24 hours post-myocardial infarction. The nurse notes
frequent premature ventricular contractions (PVCs) on the monitor. Which action should the
nurse take first?
A. Administer a bolus of Amiodarone as prescribed.
B. Prepare the patient for immediate synchronized cardioversion.
C. Check the patient’s serum potassium and magnesium levels.
D. Notify the Rapid Response Team.
Answer: C
Rationale: PVCs post-MI are often triggered by electrolyte imbalances, specifically
hypokalemia or hypomagnesemia, which can irritate the myocardium. The nurse must first
assess the underlying cause by checking laboratory values before administering
antiarrhythmics. Understanding the physiological trigger allows for targeted intervention
and prevention of lethal arrhythmias like ventricular tachycardia.
2. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation with High-Level Positive End-Expiratory Pressure (PEEP). Which assessment
finding most concerns the nurse?
A. An increase in PaO2 from 65 to 80 mmHg.
B. A decrease in cardiac output.
C. Reduced crackles on lung auscultation.
D. A respiratory rate of 18 breaths/min.
Answer: B
Rationale: High levels of PEEP increase intrathoracic pressure, which can decrease venous
return to the heart and subsequently lower cardiac output. While the goal of PEEP is to
improve oxygenation, the nurse must monitor for hemodynamic instability caused by
excessive pressure. This necessitates a careful balance between alveolar recruitment and
maintaining systemic perfusion.
3. The nurse is evaluating the effectiveness of fluid resuscitation in a patient with
hypovolemic shock. Which indicator provides the most accurate evidence of improved tissue
perfusion?
A. Blood pressure of 110/70 mmHg.
B. Urine output of 0.5 mL/kg/hr.
,C. Heart rate of 95 beats per minute.
D. Skin that is warm and dry to the touch.
Answer: B
Rationale: Urine output is a direct reflection of renal perfusion, which serves as a sensitive
indicator of overall systemic tissue perfusion. While blood pressure and heart rate are
important, they can be maintained by compensatory mechanisms even when organ
perfusion is suboptimal. A steady urine output suggests that the kidneys are receiving
enough blood flow to maintain filtration, signaling adequate resuscitation.
4. A client is admitted with Diabetic Ketoacidosis (DKA). The nurse notes the initial Arterial
Blood Gas (ABG) results: pH 7.28, PaCO2 30 mmHg, HCO3 14 mEq/L. How should the nurse
interpret these findings?
A. Respiratory alkalosis with partial compensation.
B. Respiratory acidosis with no compensation.
C. Metabolic alkalosis with full compensation.
D. Metabolic acidosis with partial compensation.
Answer: D
Rationale: The low pH indicates acidosis, and the low bicarbonate (HCO3) confirms a
metabolic origin. The low PaCO2 indicates that the lungs are attempting to compensate by
blowing off CO2 (Kussmaul respirations), but since the pH is not yet within the normal
range, it is only partially compensated. This analysis is crucial for determining the severity
of the metabolic derangement and the effectiveness of the body’s compensatory
mechanisms.
5. A patient who suffered a high-level spinal cord injury 3 months ago reports a sudden,
throbbing headache and blurred vision. The nurse finds the blood pressure is 190/110 mmHg.
What is the priority nursing intervention?
A. Administer an antihypertensive medication.
B. Place the patient in a high-Fowler’s position.
C. Perform a digital rectal exam to check for impaction.
D. Catheterize the patient to empty the bladder.
Answer: B
Rationale: The patient is exhibiting signs of Autonomic Dysreflexia, a medical emergency
common in spinal cord injuries above T6. The first priority is to sit the patient upright
(high-Fowler’s) to lower blood pressure through postural changes. After positioning, the
nurse should then identify and remove the triggering stimulus, such as a full bladder or
fecal impaction, while monitoring vitals.
, 6. During the oliguric phase of Acute Kidney Injury (AKI), which clinical manifestation should
the nurse expect to observe?
A. Hypokalemia.
B. Metabolic alkalosis.
C. Hypernatremia.
D. Fluid volume excess.
Answer: D
Rationale: In the oliguric phase of AKI, the kidneys fail to excrete urine, leading to fluid
retention and systemic volume excess. Patients typically present with symptoms such as
hypertension, edema, and weight gain. The nurse must carefully monitor for pulmonary
edema and heart failure due to the inability of the kidneys to maintain fluid balance.
7. A patient with a history of heart failure presents with a potassium level of 6.2 mEq/L.
Which EKG change should the nurse anticipate?
A. Prominent U waves.
B. Shortened PR interval.
C. Tall, peaked T waves.
D. ST-segment depression.
Answer: C
Rationale: Hyperkalemia classically causes tall, peaked T waves on an EKG due to rapid
repolarization of the ventricles. As potassium levels continue to rise, it can lead to widening
of the QRS complex and eventually cardiac arrest. Monitoring EKG changes is a priority for
the nurse to assess the risk of life-threatening arrhythmias associated with high potassium.
8. The nurse is caring for a patient with a traumatic brain injury (TBI). The nurse observes the
patient’s blood pressure increasing to 180/60 mmHg, a heart rate of 48 bpm, and an irregular
respiratory pattern. Which condition does this reflect?
A. Hypovolemic shock.
B. Neurogenic shock.
C. Cushing’s Triad.
D. Thyroid storm.
Answer: C
Rationale: Cushing’s Triad consists of widening pulse pressure (systolic hypertension),
bradycardia, and irregular respirations, signaling increased intracranial pressure (ICP).
This is a late sign of brainstem herniation and requires immediate intervention to reduce
Nursing II / PN2 (NUR2571 Final Exam) | Rasmussen
1. A nurse is caring for a patient who is 24 hours post-myocardial infarction. The nurse notes
frequent premature ventricular contractions (PVCs) on the monitor. Which action should the
nurse take first?
A. Administer a bolus of Amiodarone as prescribed.
B. Prepare the patient for immediate synchronized cardioversion.
C. Check the patient’s serum potassium and magnesium levels.
D. Notify the Rapid Response Team.
Answer: C
Rationale: PVCs post-MI are often triggered by electrolyte imbalances, specifically
hypokalemia or hypomagnesemia, which can irritate the myocardium. The nurse must first
assess the underlying cause by checking laboratory values before administering
antiarrhythmics. Understanding the physiological trigger allows for targeted intervention
and prevention of lethal arrhythmias like ventricular tachycardia.
2. A patient with Acute Respiratory Distress Syndrome (ARDS) is receiving mechanical
ventilation with High-Level Positive End-Expiratory Pressure (PEEP). Which assessment
finding most concerns the nurse?
A. An increase in PaO2 from 65 to 80 mmHg.
B. A decrease in cardiac output.
C. Reduced crackles on lung auscultation.
D. A respiratory rate of 18 breaths/min.
Answer: B
Rationale: High levels of PEEP increase intrathoracic pressure, which can decrease venous
return to the heart and subsequently lower cardiac output. While the goal of PEEP is to
improve oxygenation, the nurse must monitor for hemodynamic instability caused by
excessive pressure. This necessitates a careful balance between alveolar recruitment and
maintaining systemic perfusion.
3. The nurse is evaluating the effectiveness of fluid resuscitation in a patient with
hypovolemic shock. Which indicator provides the most accurate evidence of improved tissue
perfusion?
A. Blood pressure of 110/70 mmHg.
B. Urine output of 0.5 mL/kg/hr.
,C. Heart rate of 95 beats per minute.
D. Skin that is warm and dry to the touch.
Answer: B
Rationale: Urine output is a direct reflection of renal perfusion, which serves as a sensitive
indicator of overall systemic tissue perfusion. While blood pressure and heart rate are
important, they can be maintained by compensatory mechanisms even when organ
perfusion is suboptimal. A steady urine output suggests that the kidneys are receiving
enough blood flow to maintain filtration, signaling adequate resuscitation.
4. A client is admitted with Diabetic Ketoacidosis (DKA). The nurse notes the initial Arterial
Blood Gas (ABG) results: pH 7.28, PaCO2 30 mmHg, HCO3 14 mEq/L. How should the nurse
interpret these findings?
A. Respiratory alkalosis with partial compensation.
B. Respiratory acidosis with no compensation.
C. Metabolic alkalosis with full compensation.
D. Metabolic acidosis with partial compensation.
Answer: D
Rationale: The low pH indicates acidosis, and the low bicarbonate (HCO3) confirms a
metabolic origin. The low PaCO2 indicates that the lungs are attempting to compensate by
blowing off CO2 (Kussmaul respirations), but since the pH is not yet within the normal
range, it is only partially compensated. This analysis is crucial for determining the severity
of the metabolic derangement and the effectiveness of the body’s compensatory
mechanisms.
5. A patient who suffered a high-level spinal cord injury 3 months ago reports a sudden,
throbbing headache and blurred vision. The nurse finds the blood pressure is 190/110 mmHg.
What is the priority nursing intervention?
A. Administer an antihypertensive medication.
B. Place the patient in a high-Fowler’s position.
C. Perform a digital rectal exam to check for impaction.
D. Catheterize the patient to empty the bladder.
Answer: B
Rationale: The patient is exhibiting signs of Autonomic Dysreflexia, a medical emergency
common in spinal cord injuries above T6. The first priority is to sit the patient upright
(high-Fowler’s) to lower blood pressure through postural changes. After positioning, the
nurse should then identify and remove the triggering stimulus, such as a full bladder or
fecal impaction, while monitoring vitals.
, 6. During the oliguric phase of Acute Kidney Injury (AKI), which clinical manifestation should
the nurse expect to observe?
A. Hypokalemia.
B. Metabolic alkalosis.
C. Hypernatremia.
D. Fluid volume excess.
Answer: D
Rationale: In the oliguric phase of AKI, the kidneys fail to excrete urine, leading to fluid
retention and systemic volume excess. Patients typically present with symptoms such as
hypertension, edema, and weight gain. The nurse must carefully monitor for pulmonary
edema and heart failure due to the inability of the kidneys to maintain fluid balance.
7. A patient with a history of heart failure presents with a potassium level of 6.2 mEq/L.
Which EKG change should the nurse anticipate?
A. Prominent U waves.
B. Shortened PR interval.
C. Tall, peaked T waves.
D. ST-segment depression.
Answer: C
Rationale: Hyperkalemia classically causes tall, peaked T waves on an EKG due to rapid
repolarization of the ventricles. As potassium levels continue to rise, it can lead to widening
of the QRS complex and eventually cardiac arrest. Monitoring EKG changes is a priority for
the nurse to assess the risk of life-threatening arrhythmias associated with high potassium.
8. The nurse is caring for a patient with a traumatic brain injury (TBI). The nurse observes the
patient’s blood pressure increasing to 180/60 mmHg, a heart rate of 48 bpm, and an irregular
respiratory pattern. Which condition does this reflect?
A. Hypovolemic shock.
B. Neurogenic shock.
C. Cushing’s Triad.
D. Thyroid storm.
Answer: C
Rationale: Cushing’s Triad consists of widening pulse pressure (systolic hypertension),
bradycardia, and irregular respirations, signaling increased intracranial pressure (ICP).
This is a late sign of brainstem herniation and requires immediate intervention to reduce
