NUR 390 Exam 2 V2 | NUR 390 Nursing Care of the
Adult I | Actual Q&A with Rationale (NUR390 Exam
2) | Concordia
1. A nurse is assessing a patient with left-sided heart failure. Which of the following clinical
manifestations should the nurse expect to find?
A. Dyspnea, orthopnea, and crackles in the lungs
B. Peripheral edema and jugular venous distention
C. Hepatomegaly and abdominal girth increase
D. Splenomegaly and anorexia
Correct Answer: A
Explanation: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot pump blood effectively into the systemic circulation. This leads to fluid
backing up into the pulmonary veins and capillaries, causing respiratory symptoms like
dyspnea and crackles. Right-sided heart failure is typically associated with systemic
symptoms like peripheral edema and JVD.
2. A patient with Chronic Obstructive Pulmonary Disease (COPD) is being discharged. Which
of the following instructions should the nurse include in the teaching plan? (Select all that
apply)
A. Practice pursed-lip breathing techniques.
B. Eat high-calorie, high-protein small frequent meals.
,C. Increase fluid intake to 2 to 3 liters per day if not contraindicated.
D. Use high-flow oxygen at 6 liters per minute at all times.
E. Get an annual influenza vaccination.
F. Limit physical activity to bedrest to conserve energy.
Correct Answer: A, B, C, E
Explanation: Pursed-lip breathing helps prevent airway collapse and promotes better gas
exchange. High-calorie, high-protein meals are necessary because COPD patients have a
higher metabolic demand for breathing. Increasing fluids helps thin secretions for easier
expectoration, and vaccinations are crucial to prevent respiratory infections that could
trigger exacerbations.
3. The nurse is monitoring a patient receiving a blood transfusion. Within 15 minutes, the
patient reports low back pain and develops a fever and chills. What is the priority nursing
action?
A. Stop the transfusion immediately and disconnect the tubing at the hub.
B. Administer diphenhydramine and continue the transfusion.
C. Slow the infusion rate and notify the physician.
D. Recheck the patient’s blood type and crossmatch against the unit.
D. Recheck the patient’s blood type and crossmatch against the unit.
Correct Answer: A
,Explanation: Low back pain, fever, and chills are classic signs of a hemolytic transfusion
reaction, which is a medical emergency. The first priority is to stop the transfusion to
prevent further exposure to the incompatible blood. After stopping the infusion, the nurse
should maintain the IV line with normal saline using new tubing and notify the provider.
4. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which of the
following lab results is most consistent with this diagnosis?
A. Blood glucose 450 mg/dL and pH 7.25
B. Blood glucose 180 mg/dL and pH 7.38
C. Blood glucose 600 mg/dL and HCO3 24 mEq/L
D. Blood glucose 110 mg/dL and positive ketones
Correct Answer: A
Explanation: DKA is characterized by hyperglycemia (usually >250 mg/dL), metabolic
acidosis (pH <7.30), and the presence of ketones. A pH of 7.25 indicates acidosis, and a
glucose level of 450 mg/dL confirms significant hyperglycemia. Option C represents
Hyperosmolar Hyperglycemic State (HHS), which lacks significant acidosis.
5. Which clinical manifestation would a nurse expect to find in a patient with Peripheral
Arterial Disease (PAD)?
A. Painless ulcers on the medial malleolus
B. Brownish discoloration of the lower legs
C. Edema and thick, leathery skin
, D. Intermittent claudication and cool, pale extremities
Correct Answer: D
Explanation: Intermittent claudication is the hallmark sign of PAD, caused by muscle
ischemia during exercise. The lack of arterial blood flow also results in cool, pale, or
cyanotic skin and diminished pulses. Brownish discoloration and medial ulcers are
characteristics of chronic venous insufficiency, not arterial disease.
6. A nurse is caring for a patient who is post-operative day 1 following a total hip
arthroplasty. The patient suddenly develops sharp chest pain and dyspnea. Which
complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Myocardial infarction
D. Pneumonia
Correct Answer: B
Explanation: Sudden onset of sharp chest pain and dyspnea in a post-operative patient is
highly suggestive of a pulmonary embolism (PE). Post-operative immobility increases the
risk of DVT, which can dislodge and travel to the lungs. While MI and pneumonia are
possibilities, PE is a frequent and life-threatening complication in orthopedic surgery
patients.
Adult I | Actual Q&A with Rationale (NUR390 Exam
2) | Concordia
1. A nurse is assessing a patient with left-sided heart failure. Which of the following clinical
manifestations should the nurse expect to find?
A. Dyspnea, orthopnea, and crackles in the lungs
B. Peripheral edema and jugular venous distention
C. Hepatomegaly and abdominal girth increase
D. Splenomegaly and anorexia
Correct Answer: A
Explanation: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot pump blood effectively into the systemic circulation. This leads to fluid
backing up into the pulmonary veins and capillaries, causing respiratory symptoms like
dyspnea and crackles. Right-sided heart failure is typically associated with systemic
symptoms like peripheral edema and JVD.
2. A patient with Chronic Obstructive Pulmonary Disease (COPD) is being discharged. Which
of the following instructions should the nurse include in the teaching plan? (Select all that
apply)
A. Practice pursed-lip breathing techniques.
B. Eat high-calorie, high-protein small frequent meals.
,C. Increase fluid intake to 2 to 3 liters per day if not contraindicated.
D. Use high-flow oxygen at 6 liters per minute at all times.
E. Get an annual influenza vaccination.
F. Limit physical activity to bedrest to conserve energy.
Correct Answer: A, B, C, E
Explanation: Pursed-lip breathing helps prevent airway collapse and promotes better gas
exchange. High-calorie, high-protein meals are necessary because COPD patients have a
higher metabolic demand for breathing. Increasing fluids helps thin secretions for easier
expectoration, and vaccinations are crucial to prevent respiratory infections that could
trigger exacerbations.
3. The nurse is monitoring a patient receiving a blood transfusion. Within 15 minutes, the
patient reports low back pain and develops a fever and chills. What is the priority nursing
action?
A. Stop the transfusion immediately and disconnect the tubing at the hub.
B. Administer diphenhydramine and continue the transfusion.
C. Slow the infusion rate and notify the physician.
D. Recheck the patient’s blood type and crossmatch against the unit.
D. Recheck the patient’s blood type and crossmatch against the unit.
Correct Answer: A
,Explanation: Low back pain, fever, and chills are classic signs of a hemolytic transfusion
reaction, which is a medical emergency. The first priority is to stop the transfusion to
prevent further exposure to the incompatible blood. After stopping the infusion, the nurse
should maintain the IV line with normal saline using new tubing and notify the provider.
4. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which of the
following lab results is most consistent with this diagnosis?
A. Blood glucose 450 mg/dL and pH 7.25
B. Blood glucose 180 mg/dL and pH 7.38
C. Blood glucose 600 mg/dL and HCO3 24 mEq/L
D. Blood glucose 110 mg/dL and positive ketones
Correct Answer: A
Explanation: DKA is characterized by hyperglycemia (usually >250 mg/dL), metabolic
acidosis (pH <7.30), and the presence of ketones. A pH of 7.25 indicates acidosis, and a
glucose level of 450 mg/dL confirms significant hyperglycemia. Option C represents
Hyperosmolar Hyperglycemic State (HHS), which lacks significant acidosis.
5. Which clinical manifestation would a nurse expect to find in a patient with Peripheral
Arterial Disease (PAD)?
A. Painless ulcers on the medial malleolus
B. Brownish discoloration of the lower legs
C. Edema and thick, leathery skin
, D. Intermittent claudication and cool, pale extremities
Correct Answer: D
Explanation: Intermittent claudication is the hallmark sign of PAD, caused by muscle
ischemia during exercise. The lack of arterial blood flow also results in cool, pale, or
cyanotic skin and diminished pulses. Brownish discoloration and medial ulcers are
characteristics of chronic venous insufficiency, not arterial disease.
6. A nurse is caring for a patient who is post-operative day 1 following a total hip
arthroplasty. The patient suddenly develops sharp chest pain and dyspnea. Which
complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Myocardial infarction
D. Pneumonia
Correct Answer: B
Explanation: Sudden onset of sharp chest pain and dyspnea in a post-operative patient is
highly suggestive of a pulmonary embolism (PE). Post-operative immobility increases the
risk of DVT, which can dislodge and travel to the lungs. While MI and pneumonia are
possibilities, PE is a frequent and life-threatening complication in orthopedic surgery
patients.
