NUR 390 Exam 2 V3 | NUR 390 Nursing Care of the
Adult I | Actual Q&A with Rationale (NUR390 Exam
2) | Concordia
1. A nurse is caring for a patient with a history of COPD who is experiencing worsening
dyspnea. Which acid-base imbalance is this patient at the highest risk for developing?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis
Correct Answer: C
Explanation: Patients with COPD suffer from alveolar hypoventilation, which leads to the
retention of carbon dioxide (CO2). According to the ROME mnemonic, respiratory acidosis
occurs when CO2 levels rise and pH levels fall below the normal range. This condition
requires careful monitoring of the patient’s arterial blood gas levels and respiratory effort
to prevent further complications.
2. Which clinical manifestations should the nurse expect to find in a patient diagnosed with
right-sided heart failure? (Select All That Apply)
A. Jugular venous distension (JVD)
B. Pulmonary crackles
,C. Peripheral dependent edema
D. Ascites
E. Dyspnea on exertion
F. Hepatomegaly
Correct Answer: A, C, D, F
Explanation: Right-sided heart failure causes blood to back up into the systemic venous
circulation rather than the lungs. Manifestations such as JVD, peripheral edema, ascites,
and hepatomegaly are classic signs of systemic congestion. Pulmonary crackles and
dyspnea on exertion are typically associated with left-sided heart failure due to pulmonary
congestion.
3. A nurse is preparing to administer digoxin to a patient with heart failure. Which action is
the priority before administering the medication?
A. Assess the apical pulse for one full minute
B. Check the patient’s blood pressure
C. Review the patient’s most recent serum sodium level
D. Administer the dose if the heart rate is above 50 bpm
Correct Answer: A
Explanation: Digoxin is a cardiac glycoside that slows the heart rate while increasing
contractility. The nurse must assess the apical pulse for a full 60 seconds and withhold the
,medication if the rate is below 60 bpm in adults. Failure to perform this assessment could
lead to administering the drug during a period of severe bradycardia, worsening cardiac
output.
4. A patient with pneumonia is experiencing a decrease in oxygen saturation. Which
intervention should the nurse perform first?
A. Obtain a sputum culture
B. Administer the prescribed antibiotic
C. Elevate the head of the bed to a high-Fowler’s position
D. Encourage the patient to use the incentive spirometer
Correct Answer: C
Explanation: Positioning is the fastest and least invasive nursing intervention to improve
oxygenation in a patient with pneumonia. Elevating the head of the bed allows for
maximum chest expansion and reduces the work of breathing. While other interventions
like antibiotics and incentive spirometry are important, they are not the immediate priority
when saturation levels are dropping.
5. The nurse is providing discharge teaching for a patient with newly diagnosed hypertension.
Which dietary recommendation should the nurse include?
A. Increase intake of canned vegetables to ensure vitamin fiber
B. Use salt substitutes containing potassium liberally
C. Limit sodium intake to less than 2,300 mg per day
, D. Follow a diet high in saturated fats and refined sugars
Correct Answer: C
Explanation: The DASH (Dietary Approaches to Stop Hypertension) diet emphasizes
limiting sodium intake to manage blood pressure levels effectively. Canned vegetables
often contain high amounts of sodium as a preservative and should be avoided.
Additionally, patients taking certain antihypertensives should consult their provider before
using potassium-based salt substitutes due to the risk of hyperkalemia.
6. A patient is admitted with a suspected pulmonary embolism. Which diagnostic test is
considered the gold standard for confirming this diagnosis?
A. Chest X-ray
B. D-dimer assay
C. Electrocardiogram (ECG)
D. Spiral CT angiography
Correct Answer: D
Explanation: Spiral CT angiography (also known as CT pulmonary angiography) is the
most commonly used definitive diagnostic tool for identifying a pulmonary embolism.
While a D-dimer test can suggest the presence of a clot, it is not specific to pulmonary
emboli. Chest X-rays and ECGs are used to rule out other conditions but do not confirm the
presence of a blockage in the pulmonary vasculature.
Adult I | Actual Q&A with Rationale (NUR390 Exam
2) | Concordia
1. A nurse is caring for a patient with a history of COPD who is experiencing worsening
dyspnea. Which acid-base imbalance is this patient at the highest risk for developing?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis
Correct Answer: C
Explanation: Patients with COPD suffer from alveolar hypoventilation, which leads to the
retention of carbon dioxide (CO2). According to the ROME mnemonic, respiratory acidosis
occurs when CO2 levels rise and pH levels fall below the normal range. This condition
requires careful monitoring of the patient’s arterial blood gas levels and respiratory effort
to prevent further complications.
2. Which clinical manifestations should the nurse expect to find in a patient diagnosed with
right-sided heart failure? (Select All That Apply)
A. Jugular venous distension (JVD)
B. Pulmonary crackles
,C. Peripheral dependent edema
D. Ascites
E. Dyspnea on exertion
F. Hepatomegaly
Correct Answer: A, C, D, F
Explanation: Right-sided heart failure causes blood to back up into the systemic venous
circulation rather than the lungs. Manifestations such as JVD, peripheral edema, ascites,
and hepatomegaly are classic signs of systemic congestion. Pulmonary crackles and
dyspnea on exertion are typically associated with left-sided heart failure due to pulmonary
congestion.
3. A nurse is preparing to administer digoxin to a patient with heart failure. Which action is
the priority before administering the medication?
A. Assess the apical pulse for one full minute
B. Check the patient’s blood pressure
C. Review the patient’s most recent serum sodium level
D. Administer the dose if the heart rate is above 50 bpm
Correct Answer: A
Explanation: Digoxin is a cardiac glycoside that slows the heart rate while increasing
contractility. The nurse must assess the apical pulse for a full 60 seconds and withhold the
,medication if the rate is below 60 bpm in adults. Failure to perform this assessment could
lead to administering the drug during a period of severe bradycardia, worsening cardiac
output.
4. A patient with pneumonia is experiencing a decrease in oxygen saturation. Which
intervention should the nurse perform first?
A. Obtain a sputum culture
B. Administer the prescribed antibiotic
C. Elevate the head of the bed to a high-Fowler’s position
D. Encourage the patient to use the incentive spirometer
Correct Answer: C
Explanation: Positioning is the fastest and least invasive nursing intervention to improve
oxygenation in a patient with pneumonia. Elevating the head of the bed allows for
maximum chest expansion and reduces the work of breathing. While other interventions
like antibiotics and incentive spirometry are important, they are not the immediate priority
when saturation levels are dropping.
5. The nurse is providing discharge teaching for a patient with newly diagnosed hypertension.
Which dietary recommendation should the nurse include?
A. Increase intake of canned vegetables to ensure vitamin fiber
B. Use salt substitutes containing potassium liberally
C. Limit sodium intake to less than 2,300 mg per day
, D. Follow a diet high in saturated fats and refined sugars
Correct Answer: C
Explanation: The DASH (Dietary Approaches to Stop Hypertension) diet emphasizes
limiting sodium intake to manage blood pressure levels effectively. Canned vegetables
often contain high amounts of sodium as a preservative and should be avoided.
Additionally, patients taking certain antihypertensives should consult their provider before
using potassium-based salt substitutes due to the risk of hyperkalemia.
6. A patient is admitted with a suspected pulmonary embolism. Which diagnostic test is
considered the gold standard for confirming this diagnosis?
A. Chest X-ray
B. D-dimer assay
C. Electrocardiogram (ECG)
D. Spiral CT angiography
Correct Answer: D
Explanation: Spiral CT angiography (also known as CT pulmonary angiography) is the
most commonly used definitive diagnostic tool for identifying a pulmonary embolism.
While a D-dimer test can suggest the presence of a clot, it is not specific to pulmonary
emboli. Chest X-rays and ECGs are used to rule out other conditions but do not confirm the
presence of a blockage in the pulmonary vasculature.
