NUR 210 EXAM 2 COMPREHENSIVE
ASSESSMENT QUESTIONS AND
DETAILED SOLUTIONS LATEST
UPDATE
1. A patient with a history of heart failure is prescribed Digoxin 0.25 mg daily. The nurse notes
the patient’s potassium level is 3.2 mEq/L. Which action is the priority?
A. Hold the dose and notify the healthcare provider
B. Administer the medication as prescribed
C. Assess the patient for a heart rate greater than 60 bpm
D. Encourage the patient to eat a banana
Answer: A
Conceptual Explanation: Hypokalemia (potassium < 3.5 mEq/L) significantly increases
the risk of digoxin toxicity. The nurse must hold the medication and notify the provider to
prevent life-threatening arrhythmias.
2. An arterial blood gas (ABG) report shows: pH 7.30, PaCO2 55 mmHg, and HCO3 26 mEq/L.
How should the nurse interpret these results?
A. Uncompensated Respiratory Acidosis
B. Respiratory Alkalosis
,C. Metabolic Acidosis
D. Compensated Metabolic Alkalosis
Answer: A
Conceptual Explanation: The pH is low (<7.35), indicating acidosis. The PaCO2 is high
(>45), indicating a respiratory cause. The HCO3 is normal, meaning compensation has not
occurred.
3. Which clinical finding is most characteristic of a patient experiencing a Thyroid Storm?
A. Bradycardia and hypothermia
B. Hypotension and lethargy
C. Hyperthermia and extreme tachycardia
D. Constipation and weight gain
Answer: C
Conceptual Explanation: Thyroid storm is a life-threatening hypermetabolic state
characterized by high fever (hyperthermia), severe tachycardia, and altered mental status.
4. A client is diagnosed with Diabetes Insipidus (DI). Which laboratory value should the nurse
expect to find?
A. Serum sodium of 130 mEq/L
B. Serum osmolality of 270 mOsm/kg
C. Urine specific gravity of 1.002
, D. Urine osmolality of 800 mOsm/kg
Answer: C
Conceptual Explanation: DI is characterized by a deficiency of ADH, leading to the
excretion of large amounts of dilute urine. This results in a very low urine specific gravity
(typically < 1.005).
5. A patient is receiving Magnesium Sulfate for pre-eclampsia. Which assessment finding
requires immediate intervention?
A. Respiratory rate of 10 breaths per minute
B. Deep tendon reflexes of 2+
C. Urinary output of 40 mL per hour
D. Warmth and flushing of the skin
Answer: A
Conceptual Explanation: Magnesium toxicity causes CNS depression. A respiratory rate
below 12 is a critical sign of toxicity requiring the nurse to stop the infusion and administer
calcium gluconate.
6. Which electrolyte imbalance is a patient most at risk for when receiving a massive blood
transfusion?
A. Hypocalcemia
B. Hypernatremia
ASSESSMENT QUESTIONS AND
DETAILED SOLUTIONS LATEST
UPDATE
1. A patient with a history of heart failure is prescribed Digoxin 0.25 mg daily. The nurse notes
the patient’s potassium level is 3.2 mEq/L. Which action is the priority?
A. Hold the dose and notify the healthcare provider
B. Administer the medication as prescribed
C. Assess the patient for a heart rate greater than 60 bpm
D. Encourage the patient to eat a banana
Answer: A
Conceptual Explanation: Hypokalemia (potassium < 3.5 mEq/L) significantly increases
the risk of digoxin toxicity. The nurse must hold the medication and notify the provider to
prevent life-threatening arrhythmias.
2. An arterial blood gas (ABG) report shows: pH 7.30, PaCO2 55 mmHg, and HCO3 26 mEq/L.
How should the nurse interpret these results?
A. Uncompensated Respiratory Acidosis
B. Respiratory Alkalosis
,C. Metabolic Acidosis
D. Compensated Metabolic Alkalosis
Answer: A
Conceptual Explanation: The pH is low (<7.35), indicating acidosis. The PaCO2 is high
(>45), indicating a respiratory cause. The HCO3 is normal, meaning compensation has not
occurred.
3. Which clinical finding is most characteristic of a patient experiencing a Thyroid Storm?
A. Bradycardia and hypothermia
B. Hypotension and lethargy
C. Hyperthermia and extreme tachycardia
D. Constipation and weight gain
Answer: C
Conceptual Explanation: Thyroid storm is a life-threatening hypermetabolic state
characterized by high fever (hyperthermia), severe tachycardia, and altered mental status.
4. A client is diagnosed with Diabetes Insipidus (DI). Which laboratory value should the nurse
expect to find?
A. Serum sodium of 130 mEq/L
B. Serum osmolality of 270 mOsm/kg
C. Urine specific gravity of 1.002
, D. Urine osmolality of 800 mOsm/kg
Answer: C
Conceptual Explanation: DI is characterized by a deficiency of ADH, leading to the
excretion of large amounts of dilute urine. This results in a very low urine specific gravity
(typically < 1.005).
5. A patient is receiving Magnesium Sulfate for pre-eclampsia. Which assessment finding
requires immediate intervention?
A. Respiratory rate of 10 breaths per minute
B. Deep tendon reflexes of 2+
C. Urinary output of 40 mL per hour
D. Warmth and flushing of the skin
Answer: A
Conceptual Explanation: Magnesium toxicity causes CNS depression. A respiratory rate
below 12 is a critical sign of toxicity requiring the nurse to stop the infusion and administer
calcium gluconate.
6. Which electrolyte imbalance is a patient most at risk for when receiving a massive blood
transfusion?
A. Hypocalcemia
B. Hypernatremia
