NU 211 Introduction to Clinical Nursing
Final Assessment Review
Questions & Solutions
2025
©2025
,Multiple Choice Questions (MCQs)
A patient with chronic obstructive pulmonary disease (COPD) is admitted
with increased dyspnea and hypoxia. Which of the following nursing
interventions is the most appropriate to improve oxygenation?
A) Administer high-flow oxygen via non-rebreather mask at 15 L/min
B) Encourage pursed-lip breathing and administer low-flow oxygen at 1-2
L/min
C) Restrict fluid intake to reduce pulmonary edema
D) Provide incentive spirometry every 4 hours
ANS: B
Rationale: COPD patients are at risk of CO2 retention. Low-flow oxygen
(1-2 L/min) and pursed-lip breathing help improve oxygenation without
suppressing hypoxic drive.
In a patient receiving IV vancomycin, which clinical manifestation should
the nurse monitor to prevent red man syndrome?
A) Bradycardia and hypotension
B) Erythema and flushing of the upper body during infusion
C) Severe headache and photophobia
D) Polyuria and electrolyte imbalance
ANS: B
Rationale: Red man syndrome is characterized by flushing and rash due
to rapid vancomycin infusion, commonly treated by slowing the infusion
rate.
Which laboratory value is most indicative of acute kidney injury in a
patient with volume depletion?
A) Serum sodium 130 mEq/L
B) Blood urea nitrogen (BUN) to creatinine ratio >20:1
C) Serum potassium 3.5 mEq/L
D) Urine specific gravity of 1.005
©2025
, ANS: B
Rationale: Increased BUN:creatinine ratio (>20:1) indicates prerenal
azotemia often from volume depletion causing acute kidney injury.
In caring for a patient post-thoracentesis, which sign would warrant
immediate intervention?
A) Mild dyspnea when sitting up
B) Sudden onset of chest pain and absent breath sounds on one side
C) Slight soreness at the puncture site
D) Cough with small amounts of clear sputum
ANS: B
Rationale: Sudden chest pain and absent breath sounds could indicate
pneumothorax, a complication requiring urgent care.
A nurse is evaluating a patient on warfarin therapy. Which INR value
indicates the patient is within therapeutic range for atrial fibrillation?
A) 1.0
B) 1.5
C) 2.5
D) 4.0
ANS: C
Rationale: For atrial fibrillation, the therapeutic INR range is typically 2.0
to 3.0.
Fill-in-the-Blank Questions
The normal range for arterial blood pH is _______ to _______.
ANS: 7.35 to 7.45
Rationale: This is the physiological pH range in arterial blood maintaining
acid-base balance.
The Glasgow Coma Scale uses three criteria: eye opening, verbal
response, and _______ response.
©2025
Final Assessment Review
Questions & Solutions
2025
©2025
,Multiple Choice Questions (MCQs)
A patient with chronic obstructive pulmonary disease (COPD) is admitted
with increased dyspnea and hypoxia. Which of the following nursing
interventions is the most appropriate to improve oxygenation?
A) Administer high-flow oxygen via non-rebreather mask at 15 L/min
B) Encourage pursed-lip breathing and administer low-flow oxygen at 1-2
L/min
C) Restrict fluid intake to reduce pulmonary edema
D) Provide incentive spirometry every 4 hours
ANS: B
Rationale: COPD patients are at risk of CO2 retention. Low-flow oxygen
(1-2 L/min) and pursed-lip breathing help improve oxygenation without
suppressing hypoxic drive.
In a patient receiving IV vancomycin, which clinical manifestation should
the nurse monitor to prevent red man syndrome?
A) Bradycardia and hypotension
B) Erythema and flushing of the upper body during infusion
C) Severe headache and photophobia
D) Polyuria and electrolyte imbalance
ANS: B
Rationale: Red man syndrome is characterized by flushing and rash due
to rapid vancomycin infusion, commonly treated by slowing the infusion
rate.
Which laboratory value is most indicative of acute kidney injury in a
patient with volume depletion?
A) Serum sodium 130 mEq/L
B) Blood urea nitrogen (BUN) to creatinine ratio >20:1
C) Serum potassium 3.5 mEq/L
D) Urine specific gravity of 1.005
©2025
, ANS: B
Rationale: Increased BUN:creatinine ratio (>20:1) indicates prerenal
azotemia often from volume depletion causing acute kidney injury.
In caring for a patient post-thoracentesis, which sign would warrant
immediate intervention?
A) Mild dyspnea when sitting up
B) Sudden onset of chest pain and absent breath sounds on one side
C) Slight soreness at the puncture site
D) Cough with small amounts of clear sputum
ANS: B
Rationale: Sudden chest pain and absent breath sounds could indicate
pneumothorax, a complication requiring urgent care.
A nurse is evaluating a patient on warfarin therapy. Which INR value
indicates the patient is within therapeutic range for atrial fibrillation?
A) 1.0
B) 1.5
C) 2.5
D) 4.0
ANS: C
Rationale: For atrial fibrillation, the therapeutic INR range is typically 2.0
to 3.0.
Fill-in-the-Blank Questions
The normal range for arterial blood pH is _______ to _______.
ANS: 7.35 to 7.45
Rationale: This is the physiological pH range in arterial blood maintaining
acid-base balance.
The Glasgow Coma Scale uses three criteria: eye opening, verbal
response, and _______ response.
©2025
