NUR1212C COMPREHENSIVE FINAL
EXAM BLUEPRINT 200 CRITICAL
CLINICAL SCENARIOS WITH
CORRECT VERIFIED ANSWERS AND
HIGHLY DETAILED RATIONALES
SCORE A GUARANTEED GRADE A+ |
INSTANT PDF DOWNLOAD
NUR1212C Final Examination
1. A 67-year-old male patient with a history of chronic obstructive
pulmonary disease (COPD) is admitted to the medical-surgical
unit. During your morning assessment, you observe that he is
using accessory muscles to breathe, has a respiratory rate of 28
breaths per minute, and his oxygen saturation is 88% on room air.
Which of the following nursing interventions should you
implement first?
• Administer oxygen therapy via nasal cannula at 2 L/min
as ordered.
• Assist the patient into a supine position to maximize thoracic
expansion.
• Prepare the patient for immediate endotracheal intubation.
• Administer a scheduled dose of an oral beta-blocker.
Correct Answer Description: Hypoxemia in a COPD patient
requires immediate, controlled oxygen therapy. Elevating the
head of the bed (not supine) is preferred, and intubation is a last
resort.
2. An 82-year-old female patient is admitted with a diagnosis of
severe dehydration and urinary tract infection. She is currently
disoriented to time and place, pulling at her intravenous line, and
attempting to climb out of bed. Which of the following actions is
the most appropriate initial nursing nursing action to ensure
safety?
,• Apply bilateral soft wrist restraints tightly to the bed frame.
• Move the patient to a room closer to the nurses' station
and initiate frequent rounding.
• Administer a high dose of intramuscular haloperidol immediately.
• Turn off all room lights and leave the patient alone to decrease
stimuli.
Correct Answer Description: Environmental and behavioral
modifications must always be attempted before physical or
chemical restraints. Frequent monitoring reduces fall risks safely.
3. A nurse is preparing to administer a tube feeding via a nasogastric
(NG) tube to a patient who has been comatose following a
cerebrovascular accident. Before initiating the continuous infusion
of the formula, which action must the nurse perform to confirm
proper tube placement?
• Inject 30 mL of air into the tube while auscultating the epigastric
area.
• Aspirate gastric contents and test the pH level to ensure it
is below 5.5.
• Place the open end of the nasogastric tube in a cup of sterile water
to check for bubbles.
• Assume the tube is in the correct position if the external
measurement markings have not shifted.
Correct Answer Description: Testing the pH of gastric aspirate is
the most reliable bedside method to verify NG tube placement
short of an X-ray. Auscultation is no longer considered best
practice.
4. A 45-year-old patient underwent an open cholecystectomy 24
hours ago. During the shift assessment, the nurse notes that the
patient's abdomen is distended, firm, and there are no audible
bowel sounds in any of the four quadrants after listening for a full 5
minutes. The patient complains of severe bloating. The nurse
recognizes these findings as indicative of which postoperative
complication?
• Paralytic ileus
• Acute peritonitis
,• Intestinal evisceration
• Mechanical bowel obstruction
Correct Answer Description: Temporary absence of bowel
motility or paralytic ileus is a common postoperative
complication due to anesthesia and bowel manipulation,
characterized by absent bowel sounds and distension.
5. A nurse is caring for a patient who is receiving a continuous
intravenous infusion of heparin for a deep vein thrombosis (DVT).
Which of the following laboratory values must the nurse monitor
closely to evaluate the therapeutic effectiveness and safety of this
medication?
• Prothrombin time (PT)
• International Normalized Ratio (INR)
• Activated partial thromboplastin time (aPTT)
• Glycated hemoglobin (HbA1c)
Correct Answer Description: aPTT is the standard laboratory test
used to monitor the therapeutic effects and safety margins of
unfractionated heparin therapy.
6. While assessing a client with a history of left-sided heart failure,
the nurse auscultates the lung fields. Which adventitious breath
sounds are most consistent with this medical diagnosis due to
pulmonary congestion?
• High-pitched wheezes audible during expiration
• Fine, moist crackles heard predominantly at the lung
bases
• Loud, low-pitched snoring sounds over the main bronchi
• A harsh, grating friction rub heard during both inspiration and
expiration
Correct Answer Description: Left-sided heart failure causes blood
to back up into the pulmonary vasculature, leading to fluid
transudation into the alveoli, which manifests as crackles.
7. A patient who is 3 days postoperative from a total hip arthroplasty
suddenly complains of sharp, localized chest pain that worsens
with deep inspiration. The patient appears anxious, tachycardic,
, and tachypneic. The nurse suspects a pulmonary embolism. What
should be the nurse's immediate priority action?
• Apply supplemental oxygen via face mask and elevate the
head of the bed to high-Fowler's.
• Encourage the patient to ambulate in the hallway to clear the
lungs.
• Administer the prescribed PRN oral narcotic analgesic
immediately.
• Perform vigorous chest physiotherapy to loosen up potential
secretions.
Correct Answer Description: Immediate stabilization of
oxygenation and ventilation is the highest priority when a life-
threatening pulmonary embolism is suspected.
8. An adult client is admitted to the emergency department
presenting with deep, rapid respirations, fruity-scented breath, a
blood glucose level of 450 mg/dL, and positive ketones in the
urine. The nurse recognizes these clinical signs as characteristic of
which acid-base imbalance?
• Respiratory acidosis
• Metabolic acidosis
• Metabolic alkalosis
• Respiratory alkalosis
Correct Answer Description: Diabetic ketoacidosis (DKA) causes
an accumulation of ketones (acids), leading to metabolic acidosis,
which the body compensates for via deep, rapid Kussmaul
respirations.
9. A nurse is preparing to perform a sterile wound dressing change
for a deep surgical incision. While setting up the sterile field, the
nurse accidentally drops a sterile gauze pad onto the outer 1-inch
border of the sterile drape. Which action should the nurse take
next?
• Discard the gauze pad and use a new sterile one, as the
outer border is unsterile.
• Proceed to use the gauze pad since it landed on the drape itself.
EXAM BLUEPRINT 200 CRITICAL
CLINICAL SCENARIOS WITH
CORRECT VERIFIED ANSWERS AND
HIGHLY DETAILED RATIONALES
SCORE A GUARANTEED GRADE A+ |
INSTANT PDF DOWNLOAD
NUR1212C Final Examination
1. A 67-year-old male patient with a history of chronic obstructive
pulmonary disease (COPD) is admitted to the medical-surgical
unit. During your morning assessment, you observe that he is
using accessory muscles to breathe, has a respiratory rate of 28
breaths per minute, and his oxygen saturation is 88% on room air.
Which of the following nursing interventions should you
implement first?
• Administer oxygen therapy via nasal cannula at 2 L/min
as ordered.
• Assist the patient into a supine position to maximize thoracic
expansion.
• Prepare the patient for immediate endotracheal intubation.
• Administer a scheduled dose of an oral beta-blocker.
Correct Answer Description: Hypoxemia in a COPD patient
requires immediate, controlled oxygen therapy. Elevating the
head of the bed (not supine) is preferred, and intubation is a last
resort.
2. An 82-year-old female patient is admitted with a diagnosis of
severe dehydration and urinary tract infection. She is currently
disoriented to time and place, pulling at her intravenous line, and
attempting to climb out of bed. Which of the following actions is
the most appropriate initial nursing nursing action to ensure
safety?
,• Apply bilateral soft wrist restraints tightly to the bed frame.
• Move the patient to a room closer to the nurses' station
and initiate frequent rounding.
• Administer a high dose of intramuscular haloperidol immediately.
• Turn off all room lights and leave the patient alone to decrease
stimuli.
Correct Answer Description: Environmental and behavioral
modifications must always be attempted before physical or
chemical restraints. Frequent monitoring reduces fall risks safely.
3. A nurse is preparing to administer a tube feeding via a nasogastric
(NG) tube to a patient who has been comatose following a
cerebrovascular accident. Before initiating the continuous infusion
of the formula, which action must the nurse perform to confirm
proper tube placement?
• Inject 30 mL of air into the tube while auscultating the epigastric
area.
• Aspirate gastric contents and test the pH level to ensure it
is below 5.5.
• Place the open end of the nasogastric tube in a cup of sterile water
to check for bubbles.
• Assume the tube is in the correct position if the external
measurement markings have not shifted.
Correct Answer Description: Testing the pH of gastric aspirate is
the most reliable bedside method to verify NG tube placement
short of an X-ray. Auscultation is no longer considered best
practice.
4. A 45-year-old patient underwent an open cholecystectomy 24
hours ago. During the shift assessment, the nurse notes that the
patient's abdomen is distended, firm, and there are no audible
bowel sounds in any of the four quadrants after listening for a full 5
minutes. The patient complains of severe bloating. The nurse
recognizes these findings as indicative of which postoperative
complication?
• Paralytic ileus
• Acute peritonitis
,• Intestinal evisceration
• Mechanical bowel obstruction
Correct Answer Description: Temporary absence of bowel
motility or paralytic ileus is a common postoperative
complication due to anesthesia and bowel manipulation,
characterized by absent bowel sounds and distension.
5. A nurse is caring for a patient who is receiving a continuous
intravenous infusion of heparin for a deep vein thrombosis (DVT).
Which of the following laboratory values must the nurse monitor
closely to evaluate the therapeutic effectiveness and safety of this
medication?
• Prothrombin time (PT)
• International Normalized Ratio (INR)
• Activated partial thromboplastin time (aPTT)
• Glycated hemoglobin (HbA1c)
Correct Answer Description: aPTT is the standard laboratory test
used to monitor the therapeutic effects and safety margins of
unfractionated heparin therapy.
6. While assessing a client with a history of left-sided heart failure,
the nurse auscultates the lung fields. Which adventitious breath
sounds are most consistent with this medical diagnosis due to
pulmonary congestion?
• High-pitched wheezes audible during expiration
• Fine, moist crackles heard predominantly at the lung
bases
• Loud, low-pitched snoring sounds over the main bronchi
• A harsh, grating friction rub heard during both inspiration and
expiration
Correct Answer Description: Left-sided heart failure causes blood
to back up into the pulmonary vasculature, leading to fluid
transudation into the alveoli, which manifests as crackles.
7. A patient who is 3 days postoperative from a total hip arthroplasty
suddenly complains of sharp, localized chest pain that worsens
with deep inspiration. The patient appears anxious, tachycardic,
, and tachypneic. The nurse suspects a pulmonary embolism. What
should be the nurse's immediate priority action?
• Apply supplemental oxygen via face mask and elevate the
head of the bed to high-Fowler's.
• Encourage the patient to ambulate in the hallway to clear the
lungs.
• Administer the prescribed PRN oral narcotic analgesic
immediately.
• Perform vigorous chest physiotherapy to loosen up potential
secretions.
Correct Answer Description: Immediate stabilization of
oxygenation and ventilation is the highest priority when a life-
threatening pulmonary embolism is suspected.
8. An adult client is admitted to the emergency department
presenting with deep, rapid respirations, fruity-scented breath, a
blood glucose level of 450 mg/dL, and positive ketones in the
urine. The nurse recognizes these clinical signs as characteristic of
which acid-base imbalance?
• Respiratory acidosis
• Metabolic acidosis
• Metabolic alkalosis
• Respiratory alkalosis
Correct Answer Description: Diabetic ketoacidosis (DKA) causes
an accumulation of ketones (acids), leading to metabolic acidosis,
which the body compensates for via deep, rapid Kussmaul
respirations.
9. A nurse is preparing to perform a sterile wound dressing change
for a deep surgical incision. While setting up the sterile field, the
nurse accidentally drops a sterile gauze pad onto the outer 1-inch
border of the sterile drape. Which action should the nurse take
next?
• Discard the gauze pad and use a new sterile one, as the
outer border is unsterile.
• Proceed to use the gauze pad since it landed on the drape itself.
