NUR 215 EXAM 2 | QUESTIONS AND ANSWERS | VERIFIED
ANSWERS PLUS RATIONALES | EXAM ALREADY GRADED
A+ | LATEST EXAM
1. A patient with heart failure reports sudden weight gain of 3 pounds in 24 hours. What is
the nurse’s priority action?
A. Encourage fluid intake
B. Document the finding
C. Notify the healthcare provider
D. Reweigh in 48 hours
Answer: C. Notify the healthcare provider
Rationale: A rapid weight gain of 2–3 pounds in 24 hours indicates fluid retention and
worsening heart failure requiring immediate medical evaluation.
2. Which laboratory value is most concerning in a patient receiving furosemide?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Chloride 101 mEq/L
D. Magnesium 1.9 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Furosemide can cause hypokalemia. A potassium of 2.9 is critically low and
increases risk of dysrhythmias.
3. A patient with COPD is prescribed oxygen at 2 L/min via nasal cannula. Why is low-flow
oxygen used?
A. Prevents dry mucous membranes
B. Reduces infection risk
C. Prevents suppression of respiratory drive
D. Improves oxygen saturation faster
Answer: C. Prevents suppression of respiratory drive
Rationale: COPD patients rely on hypoxic drive. High oxygen levels can suppress their
respiratory drive.
4. Which assessment finding indicates left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Crackles in lungs
D. Hepatomegaly
,Answer: C. Crackles in lungs
Rationale: Left-sided failure causes pulmonary congestion leading to crackles and dyspnea.
5. A patient with diabetes has a blood glucose of 54 mg/dL and is conscious. What should
the nurse administer first?
A. IV dextrose
B. Glucagon IM
C. 15 grams of fast-acting carbohydrates
D. Regular insulin
Answer: C. 15 grams of fast-acting carbohydrates
Rationale: For conscious patients with hypoglycemia, oral glucose is the first-line treatment.
6. Which ECG change is associated with hyperkalemia?
A. U waves
B. Flattened T waves
C. Peaked T waves
D. Prolonged QT interval
Answer: C. Peaked T waves
Rationale: Hyperkalemia characteristically causes tall, peaked T waves.
7. A postoperative patient has absent bowel sounds. What is the priority nursing action?
A. Offer clear liquids
B. Encourage ambulation
C. Insert NG tube immediately
D. Administer laxatives
Answer: B. Encourage ambulation
Rationale: Early ambulation stimulates peristalsis and helps resolve postoperative ileus.
8. Which symptom is expected in hyperthyroidism?
A. Weight gain
B. Cold intolerance
C. Bradycardia
D. Heat intolerance
Answer: D. Heat intolerance
Rationale: Hyperthyroidism increases metabolism, leading to heat intolerance and weight loss.
9. A patient is receiving heparin therapy. Which lab monitors effectiveness?
A. PT
B. INR
C. aPTT
D. Platelet count
,Answer: C. aPTT
Rationale: Activated partial thromboplastin time (aPTT) evaluates heparin therapy.
10. Which finding indicates fluid volume deficit?
A. Bounding pulse
B. Edema
C. Decreased skin turgor
D. Crackles
Answer: C. Decreased skin turgor
Rationale: Poor skin turgor is a classic sign of dehydration.
11. A patient with pneumonia has oxygen saturation of 88%. What is the priority
intervention?
A. Encourage coughing
B. Administer oxygen
C. Increase fluids
D. Obtain sputum sample
Answer: B. Administer oxygen
Rationale: Oxygen saturation below 90% requires immediate oxygen support.
12. Which symptom is most associated with right-sided heart failure?
A. Pulmonary edema
B. Ascites
C. Orthopnea
D. Hemoptysis
Answer: B. Ascites
Rationale: Right-sided failure leads to systemic venous congestion causing ascites and
peripheral edema.
13. A patient taking warfarin should avoid which food?
A. Apples
B. White rice
C. Spinach
D. Chicken
Answer: C. Spinach
Rationale: Spinach is high in vitamin K, which decreases warfarin effectiveness.
14. Which arterial blood gas indicates metabolic acidosis?
A. pH 7.50
B. HCO₃ 30
C. pH 7.30 and HCO₃ 18
D. pCO₂ 30
, Answer: C. pH 7.30 and HCO₃ 18
Rationale: Low pH and low bicarbonate indicate metabolic acidosis.
15. Which assessment finding suggests hypocalcemia?
A. Muscle weakness
B. Positive Chvostek’s sign
C. Constipation
D. Bradycardia
Answer: B. Positive Chvostek’s sign
Rationale: Facial muscle twitching with tapping indicates hypocalcemia.
16. A patient with DKA will most likely have which finding?
A. Hypoglycemia
B. Kussmaul respirations
C. Bradycardia
D. Fluid overload
Answer: B. Kussmaul respirations
Rationale: Deep, rapid breathing compensates for metabolic acidosis in DKA.
17. Which intervention prevents DVT in hospitalized patients?
A. Bed rest
B. Leg massage
C. Sequential compression devices
D. Fluid restriction
Answer: C. Sequential compression devices
Rationale: SCDs promote venous return and reduce clot formation.
18. Which sign indicates worsening asthma attack?
A. Wheezing
B. Silent chest
C. Productive cough
D. Mild dyspnea
Answer: B. Silent chest
Rationale: Absence of breath sounds indicates severe airway obstruction.
19. A patient with cirrhosis has elevated ammonia. Which symptom is expected?
A. Confusion
B. Hypertension
C. Bradycardia
D. Polyuria
ANSWERS PLUS RATIONALES | EXAM ALREADY GRADED
A+ | LATEST EXAM
1. A patient with heart failure reports sudden weight gain of 3 pounds in 24 hours. What is
the nurse’s priority action?
A. Encourage fluid intake
B. Document the finding
C. Notify the healthcare provider
D. Reweigh in 48 hours
Answer: C. Notify the healthcare provider
Rationale: A rapid weight gain of 2–3 pounds in 24 hours indicates fluid retention and
worsening heart failure requiring immediate medical evaluation.
2. Which laboratory value is most concerning in a patient receiving furosemide?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Chloride 101 mEq/L
D. Magnesium 1.9 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Furosemide can cause hypokalemia. A potassium of 2.9 is critically low and
increases risk of dysrhythmias.
3. A patient with COPD is prescribed oxygen at 2 L/min via nasal cannula. Why is low-flow
oxygen used?
A. Prevents dry mucous membranes
B. Reduces infection risk
C. Prevents suppression of respiratory drive
D. Improves oxygen saturation faster
Answer: C. Prevents suppression of respiratory drive
Rationale: COPD patients rely on hypoxic drive. High oxygen levels can suppress their
respiratory drive.
4. Which assessment finding indicates left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Crackles in lungs
D. Hepatomegaly
,Answer: C. Crackles in lungs
Rationale: Left-sided failure causes pulmonary congestion leading to crackles and dyspnea.
5. A patient with diabetes has a blood glucose of 54 mg/dL and is conscious. What should
the nurse administer first?
A. IV dextrose
B. Glucagon IM
C. 15 grams of fast-acting carbohydrates
D. Regular insulin
Answer: C. 15 grams of fast-acting carbohydrates
Rationale: For conscious patients with hypoglycemia, oral glucose is the first-line treatment.
6. Which ECG change is associated with hyperkalemia?
A. U waves
B. Flattened T waves
C. Peaked T waves
D. Prolonged QT interval
Answer: C. Peaked T waves
Rationale: Hyperkalemia characteristically causes tall, peaked T waves.
7. A postoperative patient has absent bowel sounds. What is the priority nursing action?
A. Offer clear liquids
B. Encourage ambulation
C. Insert NG tube immediately
D. Administer laxatives
Answer: B. Encourage ambulation
Rationale: Early ambulation stimulates peristalsis and helps resolve postoperative ileus.
8. Which symptom is expected in hyperthyroidism?
A. Weight gain
B. Cold intolerance
C. Bradycardia
D. Heat intolerance
Answer: D. Heat intolerance
Rationale: Hyperthyroidism increases metabolism, leading to heat intolerance and weight loss.
9. A patient is receiving heparin therapy. Which lab monitors effectiveness?
A. PT
B. INR
C. aPTT
D. Platelet count
,Answer: C. aPTT
Rationale: Activated partial thromboplastin time (aPTT) evaluates heparin therapy.
10. Which finding indicates fluid volume deficit?
A. Bounding pulse
B. Edema
C. Decreased skin turgor
D. Crackles
Answer: C. Decreased skin turgor
Rationale: Poor skin turgor is a classic sign of dehydration.
11. A patient with pneumonia has oxygen saturation of 88%. What is the priority
intervention?
A. Encourage coughing
B. Administer oxygen
C. Increase fluids
D. Obtain sputum sample
Answer: B. Administer oxygen
Rationale: Oxygen saturation below 90% requires immediate oxygen support.
12. Which symptom is most associated with right-sided heart failure?
A. Pulmonary edema
B. Ascites
C. Orthopnea
D. Hemoptysis
Answer: B. Ascites
Rationale: Right-sided failure leads to systemic venous congestion causing ascites and
peripheral edema.
13. A patient taking warfarin should avoid which food?
A. Apples
B. White rice
C. Spinach
D. Chicken
Answer: C. Spinach
Rationale: Spinach is high in vitamin K, which decreases warfarin effectiveness.
14. Which arterial blood gas indicates metabolic acidosis?
A. pH 7.50
B. HCO₃ 30
C. pH 7.30 and HCO₃ 18
D. pCO₂ 30
, Answer: C. pH 7.30 and HCO₃ 18
Rationale: Low pH and low bicarbonate indicate metabolic acidosis.
15. Which assessment finding suggests hypocalcemia?
A. Muscle weakness
B. Positive Chvostek’s sign
C. Constipation
D. Bradycardia
Answer: B. Positive Chvostek’s sign
Rationale: Facial muscle twitching with tapping indicates hypocalcemia.
16. A patient with DKA will most likely have which finding?
A. Hypoglycemia
B. Kussmaul respirations
C. Bradycardia
D. Fluid overload
Answer: B. Kussmaul respirations
Rationale: Deep, rapid breathing compensates for metabolic acidosis in DKA.
17. Which intervention prevents DVT in hospitalized patients?
A. Bed rest
B. Leg massage
C. Sequential compression devices
D. Fluid restriction
Answer: C. Sequential compression devices
Rationale: SCDs promote venous return and reduce clot formation.
18. Which sign indicates worsening asthma attack?
A. Wheezing
B. Silent chest
C. Productive cough
D. Mild dyspnea
Answer: B. Silent chest
Rationale: Absence of breath sounds indicates severe airway obstruction.
19. A patient with cirrhosis has elevated ammonia. Which symptom is expected?
A. Confusion
B. Hypertension
C. Bradycardia
D. Polyuria
