Adult Health Nursing II – Final Exam Practice
Questions & Detailed Rationales
Question 1:
A client with acute decompensated heart failure is receiving IV furosemide. Two
hours after administration, the nurse notes a urine output of 1,200 mL, blood
pressure of 88/54 mm Hg, and potassium of 3.1 mEq/L. Which action should the
nurse take first?
A. Administer the prescribed potassium supplement
B. Hold the next dose of furosemide
C. Notify the healthcare provider of the findings
D. Encourage the client to increase oral fluid intake
Correct Answer: C. Notify the healthcare provider of the findings
Rationale: The client has significant hypotension and hypokalemia following
aggressive diuresis. These findings can compromise perfusion and increase the risk
of dysrhythmias. The provider should be notified promptly for evaluation and
adjustment of therapy. Potassium replacement may be needed, but the immediate
priority is addressing the potentially unstable hemodynamic status.
Question 2:
,A client with a recent myocardial infarction suddenly develops severe dyspnea,
pink frothy sputum, bilateral crackles, and oxygen saturation of 82%. Which
intervention should the nurse implement first?
A. Place the client in high-Fowler's position
B. Obtain a 12-lead ECG
C. Administer IV morphine
D. Encourage coughing and deep breathing
Correct Answer: A. Place the client in high-Fowler's position
Rationale: The findings indicate acute pulmonary edema, likely caused by left
ventricular failure. High-Fowler's positioning decreases venous return and
improves lung expansion, helping oxygenation immediately. Additional
interventions such as oxygen, diuretics, vasodilators, and cardiac evaluation will
follow based on the client's response and orders.
Question 3:
A client receiving unfractionated heparin for pulmonary embolism has a platelet
count that falls from 220,000/mm³ to 92,000/mm³. Which action is most
appropriate?
A. Increase the heparin infusion rate
B. Administer aspirin
C. Continue monitoring because this is expected
D. Stop heparin and notify the provider
Correct Answer: D. Stop heparin and notify the provider
,Rationale: A substantial platelet decrease during heparin therapy suggests heparin-
induced thrombocytopenia (HIT), a potentially life-threatening prothrombotic
condition. Heparin should be discontinued promptly, and the provider should be
notified. An alternative non-heparin anticoagulant is generally required to prevent
additional thrombosis.
Question 4:
A client with severe pancreatitis becomes restless and confused. The respiratory
rate is 32/min, oxygen saturation is 86% despite supplemental oxygen, and bilateral
diffuse crackles are present. Which complication should the nurse suspect?
A. Pulmonary embolism
B. Acute respiratory distress syndrome
C. Pleural effusion
D. Aspiration pneumonia
Correct Answer: B. Acute respiratory distress syndrome
Rationale: Severe pancreatitis can trigger systemic inflammation and ARDS.
Rapid respiratory deterioration, refractory hypoxemia, diffuse crackles, and
bilateral pulmonary involvement are characteristic. ARDS results from increased
alveolar-capillary permeability and requires aggressive respiratory support and
treatment of the underlying inflammatory condition.
Question 5:
, A client with cirrhosis develops increasing abdominal distention, shortness of
breath, and a 3-kg weight gain over 4 days. Which assessment finding requires the
most immediate attention?
A. Serum albumin of 2.6 g/dL
B. Bilateral ankle edema
C. Increasing abdominal girth
D. New confusion and asterixis
Correct Answer: D. New confusion and asterixis
Rationale: New confusion and asterixis strongly suggest hepatic encephalopathy
caused by accumulation of neurotoxins such as ammonia. This can progress to
decreased consciousness and airway compromise. Ascites and hypoalbuminemia
are common in cirrhosis, but acute neurological deterioration requires the most
immediate assessment and intervention.
Question 6:
A client with diabetic ketoacidosis is receiving IV fluids and an insulin infusion.
The blood glucose decreases from 520 mg/dL to 240 mg/dL. Which laboratory
value requires the nurse's closest monitoring?
A. Potassium
B. Calcium
C. Hemoglobin
D. Albumin
Correct Answer: A. Potassium
Questions & Detailed Rationales
Question 1:
A client with acute decompensated heart failure is receiving IV furosemide. Two
hours after administration, the nurse notes a urine output of 1,200 mL, blood
pressure of 88/54 mm Hg, and potassium of 3.1 mEq/L. Which action should the
nurse take first?
A. Administer the prescribed potassium supplement
B. Hold the next dose of furosemide
C. Notify the healthcare provider of the findings
D. Encourage the client to increase oral fluid intake
Correct Answer: C. Notify the healthcare provider of the findings
Rationale: The client has significant hypotension and hypokalemia following
aggressive diuresis. These findings can compromise perfusion and increase the risk
of dysrhythmias. The provider should be notified promptly for evaluation and
adjustment of therapy. Potassium replacement may be needed, but the immediate
priority is addressing the potentially unstable hemodynamic status.
Question 2:
,A client with a recent myocardial infarction suddenly develops severe dyspnea,
pink frothy sputum, bilateral crackles, and oxygen saturation of 82%. Which
intervention should the nurse implement first?
A. Place the client in high-Fowler's position
B. Obtain a 12-lead ECG
C. Administer IV morphine
D. Encourage coughing and deep breathing
Correct Answer: A. Place the client in high-Fowler's position
Rationale: The findings indicate acute pulmonary edema, likely caused by left
ventricular failure. High-Fowler's positioning decreases venous return and
improves lung expansion, helping oxygenation immediately. Additional
interventions such as oxygen, diuretics, vasodilators, and cardiac evaluation will
follow based on the client's response and orders.
Question 3:
A client receiving unfractionated heparin for pulmonary embolism has a platelet
count that falls from 220,000/mm³ to 92,000/mm³. Which action is most
appropriate?
A. Increase the heparin infusion rate
B. Administer aspirin
C. Continue monitoring because this is expected
D. Stop heparin and notify the provider
Correct Answer: D. Stop heparin and notify the provider
,Rationale: A substantial platelet decrease during heparin therapy suggests heparin-
induced thrombocytopenia (HIT), a potentially life-threatening prothrombotic
condition. Heparin should be discontinued promptly, and the provider should be
notified. An alternative non-heparin anticoagulant is generally required to prevent
additional thrombosis.
Question 4:
A client with severe pancreatitis becomes restless and confused. The respiratory
rate is 32/min, oxygen saturation is 86% despite supplemental oxygen, and bilateral
diffuse crackles are present. Which complication should the nurse suspect?
A. Pulmonary embolism
B. Acute respiratory distress syndrome
C. Pleural effusion
D. Aspiration pneumonia
Correct Answer: B. Acute respiratory distress syndrome
Rationale: Severe pancreatitis can trigger systemic inflammation and ARDS.
Rapid respiratory deterioration, refractory hypoxemia, diffuse crackles, and
bilateral pulmonary involvement are characteristic. ARDS results from increased
alveolar-capillary permeability and requires aggressive respiratory support and
treatment of the underlying inflammatory condition.
Question 5:
, A client with cirrhosis develops increasing abdominal distention, shortness of
breath, and a 3-kg weight gain over 4 days. Which assessment finding requires the
most immediate attention?
A. Serum albumin of 2.6 g/dL
B. Bilateral ankle edema
C. Increasing abdominal girth
D. New confusion and asterixis
Correct Answer: D. New confusion and asterixis
Rationale: New confusion and asterixis strongly suggest hepatic encephalopathy
caused by accumulation of neurotoxins such as ammonia. This can progress to
decreased consciousness and airway compromise. Ascites and hypoalbuminemia
are common in cirrhosis, but acute neurological deterioration requires the most
immediate assessment and intervention.
Question 6:
A client with diabetic ketoacidosis is receiving IV fluids and an insulin infusion.
The blood glucose decreases from 520 mg/dL to 240 mg/dL. Which laboratory
value requires the nurse's closest monitoring?
A. Potassium
B. Calcium
C. Hemoglobin
D. Albumin
Correct Answer: A. Potassium
