NUR2058 Exam 3 V2 | NUR 2058 Dimensions of
Nursing Practice Exam Q&A | Rasmussen
University
1. A patient is admitted with a diagnosis of acute myocardial infarction. Which assessment
finding is most concerning to the nurse?
A. Occasional premature ventricular contractions (PVCs)
B. Report of 3/10 chest pain
C. Blood pressure of 140/90 mmHg
D. Crackle sounds in the lung bases
Correct Answer: D
Explanation: Crackles in the lungs indicate the development of pulmonary edema, which is
a sign of heart failure following a myocardial infarction. This represents a compromise in
circulation and oxygenation that requires immediate intervention. The nurse must
prioritize airway and breathing assessments in this clinical scenario.
2. The nurse is caring for a postoperative patient. Which intervention is most effective in
preventing pulmonary embolism?
A. Performing deep breathing exercises every hour
B. Early and frequent ambulation
C. Increasing fluid intake to 3000 mL per day
,D. Administering low-dose aspirin as ordered
Correct Answer: B
Explanation: Early ambulation is the most effective nursing intervention to prevent
venous stasis and subsequent deep vein thrombosis or pulmonary embolism. While
hydration and breathing exercises are important for general recovery, they do not address
the mechanical stasis of blood in the lower extremities. The nurse should encourage the
patient to walk as soon as they are hemodynamically stable.
3. A patient with a history of COPD is receiving oxygen via nasal cannula at 2L/min. Which
finding suggests the oxygen flow rate may be too high?
A. Respiratory rate of 20 breaths per minute
B. Oxygen saturation of 92%
C. Increased lethargy and confusion
D. Pulse rate of 88 beats per minute
Correct Answer: C
Explanation: In patients with chronic obstructive pulmonary disease (COPD), a high
concentration of oxygen can suppress the hypoxic drive, leading to CO2 retention.
Increased lethargy and confusion are clinical signs of carbon dioxide narcosis. The nurse
must monitor mental status closely when adjusting oxygen levels in this population.
, 4. Which task is most appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
A. Performing a sterile dressing change on a post-op wound
B. Assisting a stable patient with a bed bath
C. Evaluating the effectiveness of pain medication
D. Teaching a patient how to use an incentive spirometer
Correct Answer: B
Explanation: Delegation to UAPs should focus on routine tasks that do not require clinical
judgment or specialized assessment. Assisting with activities of daily living, such as a bed
bath for a stable patient, falls within their scope. Evaluation, teaching, and sterile
procedures are responsibilities that must remain with the licensed nurse.
5. The nurse is preparing to administer digoxin to a patient with heart failure. Which action
should the nurse take first?
A. Check the patient’s blood pressure
B. Review the patient’s latest potassium level
C. Assess the apical pulse for one full minute
D. Administer the medication with food
Correct Answer: C
Nursing Practice Exam Q&A | Rasmussen
University
1. A patient is admitted with a diagnosis of acute myocardial infarction. Which assessment
finding is most concerning to the nurse?
A. Occasional premature ventricular contractions (PVCs)
B. Report of 3/10 chest pain
C. Blood pressure of 140/90 mmHg
D. Crackle sounds in the lung bases
Correct Answer: D
Explanation: Crackles in the lungs indicate the development of pulmonary edema, which is
a sign of heart failure following a myocardial infarction. This represents a compromise in
circulation and oxygenation that requires immediate intervention. The nurse must
prioritize airway and breathing assessments in this clinical scenario.
2. The nurse is caring for a postoperative patient. Which intervention is most effective in
preventing pulmonary embolism?
A. Performing deep breathing exercises every hour
B. Early and frequent ambulation
C. Increasing fluid intake to 3000 mL per day
,D. Administering low-dose aspirin as ordered
Correct Answer: B
Explanation: Early ambulation is the most effective nursing intervention to prevent
venous stasis and subsequent deep vein thrombosis or pulmonary embolism. While
hydration and breathing exercises are important for general recovery, they do not address
the mechanical stasis of blood in the lower extremities. The nurse should encourage the
patient to walk as soon as they are hemodynamically stable.
3. A patient with a history of COPD is receiving oxygen via nasal cannula at 2L/min. Which
finding suggests the oxygen flow rate may be too high?
A. Respiratory rate of 20 breaths per minute
B. Oxygen saturation of 92%
C. Increased lethargy and confusion
D. Pulse rate of 88 beats per minute
Correct Answer: C
Explanation: In patients with chronic obstructive pulmonary disease (COPD), a high
concentration of oxygen can suppress the hypoxic drive, leading to CO2 retention.
Increased lethargy and confusion are clinical signs of carbon dioxide narcosis. The nurse
must monitor mental status closely when adjusting oxygen levels in this population.
, 4. Which task is most appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
A. Performing a sterile dressing change on a post-op wound
B. Assisting a stable patient with a bed bath
C. Evaluating the effectiveness of pain medication
D. Teaching a patient how to use an incentive spirometer
Correct Answer: B
Explanation: Delegation to UAPs should focus on routine tasks that do not require clinical
judgment or specialized assessment. Assisting with activities of daily living, such as a bed
bath for a stable patient, falls within their scope. Evaluation, teaching, and sterile
procedures are responsibilities that must remain with the licensed nurse.
5. The nurse is preparing to administer digoxin to a patient with heart failure. Which action
should the nurse take first?
A. Check the patient’s blood pressure
B. Review the patient’s latest potassium level
C. Assess the apical pulse for one full minute
D. Administer the medication with food
Correct Answer: C
