NUR256 EXAM 3 [LATEST 2024\2025 WITH WELL ELABORATED
ANSWERS[LATEST]
Question 1
A 68-year-old male patient with a history of chronic obstructive pulmonary disease
(COPD) is admitted to the hospital with increasing shortness of breath and productive
cough. His oxygen saturation is 88% on room air. What is the most appropriate initial
intervention?
Answer:
The most appropriate initial intervention for this patient is to administer supplemental oxygen to
improve his oxygen saturation. Since the patient has COPD, it is crucial to provide oxygen
carefully to avoid suppressing his respiratory drive. A target oxygen saturation of 88-92% is
generally recommended.
1. Administer low-flow supplemental oxygen via nasal cannula at 1-2 liters per minute.
2. Monitor the patient’s oxygen saturation and adjust the oxygen flow rate as needed
to maintain the target range.
3. Perform a thorough respiratory assessment, including auscultation of lung sounds
and measurement of respiratory rate and effort.
4. Encourage the patient to use diaphragmatic breathing techniques and to
expectorate any mucus.
5. Obtain an arterial blood gas (ABG) analysis to assess the patient’s oxygenation and
acid-base status.
These steps ensure the patient’s oxygen needs are met while avoiding complications associated
with excessive oxygen therapy in COPD patients.
Question 2
A nurse is assessing a patient who has been diagnosed with heart failure. Which of the
following symptoms should the nurse expect to find in this patient? Select all that apply.
A. Weight loss
B. Edema
C. Shortness of breath
D. Bradycardia
E. Orthopnea
Answer:
B. Edema
C. Shortness of breath
E. Orthopnea
,Heart failure often leads to fluid accumulation in the body, which causes edema (swelling,
particularly in the lower extremities). Shortness of breath occurs due to fluid accumulation in the
lungs (pulmonary congestion). Orthopnea (difficulty breathing when lying flat) is a common
symptom as well because the recumbent position increases venous return to the heart, worsening
pulmonary congestion.
Weight loss (A) is not typically associated with heart failure; patients more commonly
experience weight gain due to fluid retention. Bradycardia (D) is not a common symptom of
heart failure; instead, patients may experience tachycardia as the heart attempts to compensate
for decreased cardiac output.
Question 3
A 45-year-old female patient presents with acute abdominal pain, nausea, and vomiting.
She is diagnosed with acute pancreatitis. Which of the following laboratory findings is most
indicative of acute pancreatitis?
A. Elevated bilirubin
B. Elevated amylase and lipase
C. Elevated alkaline phosphatase
D. Elevated creatinine
Answer:
B. Elevated amylase and lipase
Acute pancreatitis is characterized by inflammation of the pancreas, leading to elevated levels of
pancreatic enzymes in the blood. Amylase and lipase are the key enzymes produced by the
pancreas, and their elevated levels are the most indicative of acute pancreatitis. While other
laboratory values can be abnormal in pancreatitis, amylase and lipase are the most specific
indicators.
Question 4
A patient with type 2 diabetes is being educated about managing their condition. Which of
the following statements indicates that the patient understands the teaching?
A. "I should skip meals if my blood sugar is high."
B. "I need to eat a consistent amount of carbohydrates with each meal."
C. "I don't need to check my blood sugar if I feel fine."
D. "I can eat whatever I want as long as I take my medication."
Answer:
B. "I need to eat a consistent amount of carbohydrates with each meal."
, Consistent carbohydrate intake helps to maintain stable blood sugar levels, which is essential for
managing diabetes. Skipping meals (A) can lead to hypoglycemia. Regular blood sugar
monitoring (C) is necessary even if the patient feels fine, as blood sugar levels can be
unpredictable. Eating whatever one wants (D) is not advisable, as it can lead to poor blood sugar
control despite medication.
Question 5
A patient with a history of hypertension is prescribed a new antihypertensive medication.
What is the most important instruction the nurse should give the patient?
A. "Take this medication only when you feel your blood pressure is high."
B. "It's okay to stop taking the medication once your blood pressure is normal."
C. "You should change your diet to include more salt."
D. "Take the medication at the same time every day."
Answer:
D. "Take the medication at the same time every day."
Antihypertensive medications should be taken consistently at the same time each day to maintain
stable blood pressure levels. Only taking the medication when feeling hypertensive (A) or
stopping it when blood pressure is normal (B) can lead to uncontrolled hypertension and
increased risk of complications. Increasing salt intake (C) is counterproductive for a patient with
hypertension.
Question 6
A 52-year-old male presents with severe chest pain radiating to his left arm and jaw,
sweating, and shortness of breath. What is the most appropriate initial intervention?
Answer:
The most appropriate initial intervention for a patient presenting with symptoms suggestive of a
myocardial infarction (heart attack) includes the following steps, often remembered by the
acronym MONA:
1. Administer oxygen if hypoxemic: Ensure the patient has adequate oxygenation.
Supplemental oxygen is recommended if the oxygen saturation is below 94%.
2. Administer aspirin: Give 160-325 mg of aspirin to chew to help inhibit platelet
aggregation.
3. Administer nitroglycerin: If not contraindicated, administer nitroglycerin sublingually
to reduce chest pain and improve blood flow to the heart.
ANSWERS[LATEST]
Question 1
A 68-year-old male patient with a history of chronic obstructive pulmonary disease
(COPD) is admitted to the hospital with increasing shortness of breath and productive
cough. His oxygen saturation is 88% on room air. What is the most appropriate initial
intervention?
Answer:
The most appropriate initial intervention for this patient is to administer supplemental oxygen to
improve his oxygen saturation. Since the patient has COPD, it is crucial to provide oxygen
carefully to avoid suppressing his respiratory drive. A target oxygen saturation of 88-92% is
generally recommended.
1. Administer low-flow supplemental oxygen via nasal cannula at 1-2 liters per minute.
2. Monitor the patient’s oxygen saturation and adjust the oxygen flow rate as needed
to maintain the target range.
3. Perform a thorough respiratory assessment, including auscultation of lung sounds
and measurement of respiratory rate and effort.
4. Encourage the patient to use diaphragmatic breathing techniques and to
expectorate any mucus.
5. Obtain an arterial blood gas (ABG) analysis to assess the patient’s oxygenation and
acid-base status.
These steps ensure the patient’s oxygen needs are met while avoiding complications associated
with excessive oxygen therapy in COPD patients.
Question 2
A nurse is assessing a patient who has been diagnosed with heart failure. Which of the
following symptoms should the nurse expect to find in this patient? Select all that apply.
A. Weight loss
B. Edema
C. Shortness of breath
D. Bradycardia
E. Orthopnea
Answer:
B. Edema
C. Shortness of breath
E. Orthopnea
,Heart failure often leads to fluid accumulation in the body, which causes edema (swelling,
particularly in the lower extremities). Shortness of breath occurs due to fluid accumulation in the
lungs (pulmonary congestion). Orthopnea (difficulty breathing when lying flat) is a common
symptom as well because the recumbent position increases venous return to the heart, worsening
pulmonary congestion.
Weight loss (A) is not typically associated with heart failure; patients more commonly
experience weight gain due to fluid retention. Bradycardia (D) is not a common symptom of
heart failure; instead, patients may experience tachycardia as the heart attempts to compensate
for decreased cardiac output.
Question 3
A 45-year-old female patient presents with acute abdominal pain, nausea, and vomiting.
She is diagnosed with acute pancreatitis. Which of the following laboratory findings is most
indicative of acute pancreatitis?
A. Elevated bilirubin
B. Elevated amylase and lipase
C. Elevated alkaline phosphatase
D. Elevated creatinine
Answer:
B. Elevated amylase and lipase
Acute pancreatitis is characterized by inflammation of the pancreas, leading to elevated levels of
pancreatic enzymes in the blood. Amylase and lipase are the key enzymes produced by the
pancreas, and their elevated levels are the most indicative of acute pancreatitis. While other
laboratory values can be abnormal in pancreatitis, amylase and lipase are the most specific
indicators.
Question 4
A patient with type 2 diabetes is being educated about managing their condition. Which of
the following statements indicates that the patient understands the teaching?
A. "I should skip meals if my blood sugar is high."
B. "I need to eat a consistent amount of carbohydrates with each meal."
C. "I don't need to check my blood sugar if I feel fine."
D. "I can eat whatever I want as long as I take my medication."
Answer:
B. "I need to eat a consistent amount of carbohydrates with each meal."
, Consistent carbohydrate intake helps to maintain stable blood sugar levels, which is essential for
managing diabetes. Skipping meals (A) can lead to hypoglycemia. Regular blood sugar
monitoring (C) is necessary even if the patient feels fine, as blood sugar levels can be
unpredictable. Eating whatever one wants (D) is not advisable, as it can lead to poor blood sugar
control despite medication.
Question 5
A patient with a history of hypertension is prescribed a new antihypertensive medication.
What is the most important instruction the nurse should give the patient?
A. "Take this medication only when you feel your blood pressure is high."
B. "It's okay to stop taking the medication once your blood pressure is normal."
C. "You should change your diet to include more salt."
D. "Take the medication at the same time every day."
Answer:
D. "Take the medication at the same time every day."
Antihypertensive medications should be taken consistently at the same time each day to maintain
stable blood pressure levels. Only taking the medication when feeling hypertensive (A) or
stopping it when blood pressure is normal (B) can lead to uncontrolled hypertension and
increased risk of complications. Increasing salt intake (C) is counterproductive for a patient with
hypertension.
Question 6
A 52-year-old male presents with severe chest pain radiating to his left arm and jaw,
sweating, and shortness of breath. What is the most appropriate initial intervention?
Answer:
The most appropriate initial intervention for a patient presenting with symptoms suggestive of a
myocardial infarction (heart attack) includes the following steps, often remembered by the
acronym MONA:
1. Administer oxygen if hypoxemic: Ensure the patient has adequate oxygenation.
Supplemental oxygen is recommended if the oxygen saturation is below 94%.
2. Administer aspirin: Give 160-325 mg of aspirin to chew to help inhibit platelet
aggregation.
3. Administer nitroglycerin: If not contraindicated, administer nitroglycerin sublingually
to reduce chest pain and improve blood flow to the heart.
