PRN1409 Client-Centered Care III
ACTUAL EXAM 2024/2025 | Final
Exam Comprehensive Review |
Rasmussen University | Latest Update |
Verified Q&A | Pass Guaranteed - A+
Graded
UNIT 1: COMPLEX MEDICAL-SURGICAL NURSING
Q1: Heart Failure – Furosemide Administration
A client with heart failure is receiving furosemide (Lasix) 40 mg IV push. Which
assessment finding requires immediate intervention by the practical nurse?
A. Urinary output of 250 mL in the past 2 hours
B. Serum potassium level of 3.2 mEq/L [CORRECT]
C. Blood pressure of 110/70 mmHg
D. Weight decrease of 2 kg in 24 hours
Correct Answer: B
Rationale:
Furosemide is a loop diuretic that causes potassium wasting via the ascending loop of
Henle . A serum potassium level of 3.2 mEq/L (normal: 3.5–5.0 mEq/L) increases the risk of
cardiac dysrhythmias, particularly in clients also receiving digoxin (hypokalemia potentiates
digoxin toxicity). This finding requires immediate notification of the RN or provider and
potential potassium supplementation or dietary adjustments.
● Urinary output of 250 mL in 2 hours (A) is adequate (minimum: 30 mL/hr).
● BP 110/70 mmHg (C) is within normal limits for a client on diuretics.
● Weight decrease of 2 kg in 24 hours (D) reflects expected diuresis (1 kg ≈ 1 L fluid
loss).
Rasmussen Note:
, ● Loop diuretics (e.g., furosemide, bumetanide):
○ Monitor electrolytes (K⁺, Na⁺, Mg²⁺, Ca²⁺).
○ Assess for hypovolemia (dizziness, hypotension, tachycardia).
○ Teach client to weigh daily, report weight loss >2 lbs/day, and increase
potassium-rich foods (bananas, oranges, spinach).
Q2: Diabetes Mellitus – Metformin Teaching
The practical nurse is reinforcing teaching for a client newly diagnosed with type 2
diabetes mellitus. Which statement by the client indicates understanding of the
prescribed metformin?
A. "I will take this medication when my blood sugar is high."
B. "I may have a metallic taste in my mouth while taking this medication."
C. "I will take this medication with meals to prevent stomach upset." [CORRECT]
D. "I need to check my blood sugar every hour for the first week."
Correct Answer: C
Rationale:
Metformin is a biguanide that decreases hepatic glucose production and improves insulin
sensitivity. It is taken regularly with meals to reduce gastrointestinal side effects (nausea,
diarrhea, abdominal discomfort). Taking it only when blood sugar is high (A) is incorrect;
metformin is not for acute hyperglycemia management. A metallic taste (B) is associated
with metronidazole , not metformin. Hourly blood sugar monitoring (D) is unnecessary for
stable type 2 diabetes managed with metformin alone.
Rasmussen Note:
● Metformin key points:
○ First-line oral agent for type 2 diabetes.
○ Contraindicated in renal impairment (CrCl <30 mL/min) due to lactic acidosis
risk.
○ Teach client to report signs of lactic acidosis (fatigue, muscle pain, dyspnea,
abdominal pain).
Q3: Myocardial Infarction – Nitroglycerin Administration
A client experiencing chest pain is prescribed sublingual nitroglycerin. Which action by
the practical nurse is most appropriate?
A. Administer the nitroglycerin and reassess pain in 30 minutes
B. Check the client’s blood pressure before administering nitroglycerin [CORRECT]
,C. Hold the nitroglycerin if the client’s heart rate is 88 bpm
D. Instruct the client to swallow the tablet with water for faster absorption
Correct Answer: B
Rationale:
Nitroglycerin is a vasodilator that can cause hypotension. Blood pressure must be
checked before administration to ensure it is ≥90/60 mmHg (hypotension is a
contraindication). Pain should be reassessed 5 minutes after administration (A), not 30
minutes. Heart rate of 88 bpm (C) is not a contraindication. Nitroglycerin is sublingual only
(D); swallowing reduces efficacy.
Rasmussen Note:
● Nitroglycerin administration:
○ Sublingual tablet or spray (do not chew/swallow).
○ Max dose : 3 doses, 5 minutes apart.
○ Side effects: Headache, hypotension, flushing.
○ Contraindications: Hypotension, PDE-5 inhibitors (e.g., sildenafil),
increased ICP.
Q4: COPD – Pursed-Lip Breathing Teaching
The practical nurse is teaching pursed-lip breathing to a client with chronic obstructive
pulmonary disease (COPD). Which statement by the client indicates correct
understanding?
A. "I should inhale through my mouth and exhale through my nose."
B. "I will inhale through my nose and exhale slowly through pursed lips." [CORRECT]
C. "I need to hold my breath for 10 seconds after inhaling."
D. "This technique will cure my shortness of breath permanently."
Correct Answer: B
Rationale:
Pursed-lip breathing slows exhalation, prevents airway collapse , and improves
oxygenation by:
● Inhaling through the nose (filters and warms air).
● Exhaling through pursed lips (creates backpressure, keeps airways open).
Inhaling through the mouth (A) dries mucosal membranes. Holding breath (C) is not
part of pursed-lip breathing. This technique manages symptoms but does not cure
COPD (D).
Rasmussen Note:
● COPD management:
, ○ Bronchodilators (SABA, LABA, anticholinergics).
○ Oxygen therapy (if SpO₂ <88%).
○ Pulmonary rehab (exercise, nutrition, breathing techniques).
○ Avoid irritants (smoke, pollution).
Q5: Stroke – Hemiplegia Care
A client with right-sided hemiplegia following a left hemisphere stroke requires
assistance with activities of daily living (ADLs). Which action by the practical nurse is
most appropriate?
A. Perform all ADLs for the client to prevent fatigue
B. Encourage the client to use the unaffected left side and assist as needed
[CORRECT]
C. Place the client in a wheelchair without a footrest to promote standing
D. Position the client’s right arm in a dependent position to prevent contractures
Correct Answer: B
Rationale:
Right-sided hemiplegia results from a left hemisphere stroke (controls right side).
Encouraging use of the unaffected left side promotes independence and prevents
learned helplessness. Performing all ADLs (A) reduces motivation for recovery. A
wheelchair requires a footrest (C) to prevent foot drop. The affected arm should be
elevated (D) (e.g., pillow support) to prevent edema and contractures.
Rasmussen Note:
● Stroke rehabilitation:
○ Positioning: Elevate affected limb, avoid pressure on joints.
○ Mobility: Turn q2h, ROM exercises, assist with transfers.
○ Communication: Aphasia management (speech therapy, picture boards).
Q6: Acute Kidney Injury – Fluid Balance
A client with acute kidney injury (AKI) has a 24-hour urine output of 300 mL. Which
intervention is priority for the practical nurse?
A. Encourage the client to drink 3 L of water daily
B. Monitor strict intake and output and notify the RN of oliguria [CORRECT]
C. Administer IV furosemide 40 mg as ordered
D. Measure abdominal girth every 4 hours
ACTUAL EXAM 2024/2025 | Final
Exam Comprehensive Review |
Rasmussen University | Latest Update |
Verified Q&A | Pass Guaranteed - A+
Graded
UNIT 1: COMPLEX MEDICAL-SURGICAL NURSING
Q1: Heart Failure – Furosemide Administration
A client with heart failure is receiving furosemide (Lasix) 40 mg IV push. Which
assessment finding requires immediate intervention by the practical nurse?
A. Urinary output of 250 mL in the past 2 hours
B. Serum potassium level of 3.2 mEq/L [CORRECT]
C. Blood pressure of 110/70 mmHg
D. Weight decrease of 2 kg in 24 hours
Correct Answer: B
Rationale:
Furosemide is a loop diuretic that causes potassium wasting via the ascending loop of
Henle . A serum potassium level of 3.2 mEq/L (normal: 3.5–5.0 mEq/L) increases the risk of
cardiac dysrhythmias, particularly in clients also receiving digoxin (hypokalemia potentiates
digoxin toxicity). This finding requires immediate notification of the RN or provider and
potential potassium supplementation or dietary adjustments.
● Urinary output of 250 mL in 2 hours (A) is adequate (minimum: 30 mL/hr).
● BP 110/70 mmHg (C) is within normal limits for a client on diuretics.
● Weight decrease of 2 kg in 24 hours (D) reflects expected diuresis (1 kg ≈ 1 L fluid
loss).
Rasmussen Note:
, ● Loop diuretics (e.g., furosemide, bumetanide):
○ Monitor electrolytes (K⁺, Na⁺, Mg²⁺, Ca²⁺).
○ Assess for hypovolemia (dizziness, hypotension, tachycardia).
○ Teach client to weigh daily, report weight loss >2 lbs/day, and increase
potassium-rich foods (bananas, oranges, spinach).
Q2: Diabetes Mellitus – Metformin Teaching
The practical nurse is reinforcing teaching for a client newly diagnosed with type 2
diabetes mellitus. Which statement by the client indicates understanding of the
prescribed metformin?
A. "I will take this medication when my blood sugar is high."
B. "I may have a metallic taste in my mouth while taking this medication."
C. "I will take this medication with meals to prevent stomach upset." [CORRECT]
D. "I need to check my blood sugar every hour for the first week."
Correct Answer: C
Rationale:
Metformin is a biguanide that decreases hepatic glucose production and improves insulin
sensitivity. It is taken regularly with meals to reduce gastrointestinal side effects (nausea,
diarrhea, abdominal discomfort). Taking it only when blood sugar is high (A) is incorrect;
metformin is not for acute hyperglycemia management. A metallic taste (B) is associated
with metronidazole , not metformin. Hourly blood sugar monitoring (D) is unnecessary for
stable type 2 diabetes managed with metformin alone.
Rasmussen Note:
● Metformin key points:
○ First-line oral agent for type 2 diabetes.
○ Contraindicated in renal impairment (CrCl <30 mL/min) due to lactic acidosis
risk.
○ Teach client to report signs of lactic acidosis (fatigue, muscle pain, dyspnea,
abdominal pain).
Q3: Myocardial Infarction – Nitroglycerin Administration
A client experiencing chest pain is prescribed sublingual nitroglycerin. Which action by
the practical nurse is most appropriate?
A. Administer the nitroglycerin and reassess pain in 30 minutes
B. Check the client’s blood pressure before administering nitroglycerin [CORRECT]
,C. Hold the nitroglycerin if the client’s heart rate is 88 bpm
D. Instruct the client to swallow the tablet with water for faster absorption
Correct Answer: B
Rationale:
Nitroglycerin is a vasodilator that can cause hypotension. Blood pressure must be
checked before administration to ensure it is ≥90/60 mmHg (hypotension is a
contraindication). Pain should be reassessed 5 minutes after administration (A), not 30
minutes. Heart rate of 88 bpm (C) is not a contraindication. Nitroglycerin is sublingual only
(D); swallowing reduces efficacy.
Rasmussen Note:
● Nitroglycerin administration:
○ Sublingual tablet or spray (do not chew/swallow).
○ Max dose : 3 doses, 5 minutes apart.
○ Side effects: Headache, hypotension, flushing.
○ Contraindications: Hypotension, PDE-5 inhibitors (e.g., sildenafil),
increased ICP.
Q4: COPD – Pursed-Lip Breathing Teaching
The practical nurse is teaching pursed-lip breathing to a client with chronic obstructive
pulmonary disease (COPD). Which statement by the client indicates correct
understanding?
A. "I should inhale through my mouth and exhale through my nose."
B. "I will inhale through my nose and exhale slowly through pursed lips." [CORRECT]
C. "I need to hold my breath for 10 seconds after inhaling."
D. "This technique will cure my shortness of breath permanently."
Correct Answer: B
Rationale:
Pursed-lip breathing slows exhalation, prevents airway collapse , and improves
oxygenation by:
● Inhaling through the nose (filters and warms air).
● Exhaling through pursed lips (creates backpressure, keeps airways open).
Inhaling through the mouth (A) dries mucosal membranes. Holding breath (C) is not
part of pursed-lip breathing. This technique manages symptoms but does not cure
COPD (D).
Rasmussen Note:
● COPD management:
, ○ Bronchodilators (SABA, LABA, anticholinergics).
○ Oxygen therapy (if SpO₂ <88%).
○ Pulmonary rehab (exercise, nutrition, breathing techniques).
○ Avoid irritants (smoke, pollution).
Q5: Stroke – Hemiplegia Care
A client with right-sided hemiplegia following a left hemisphere stroke requires
assistance with activities of daily living (ADLs). Which action by the practical nurse is
most appropriate?
A. Perform all ADLs for the client to prevent fatigue
B. Encourage the client to use the unaffected left side and assist as needed
[CORRECT]
C. Place the client in a wheelchair without a footrest to promote standing
D. Position the client’s right arm in a dependent position to prevent contractures
Correct Answer: B
Rationale:
Right-sided hemiplegia results from a left hemisphere stroke (controls right side).
Encouraging use of the unaffected left side promotes independence and prevents
learned helplessness. Performing all ADLs (A) reduces motivation for recovery. A
wheelchair requires a footrest (C) to prevent foot drop. The affected arm should be
elevated (D) (e.g., pillow support) to prevent edema and contractures.
Rasmussen Note:
● Stroke rehabilitation:
○ Positioning: Elevate affected limb, avoid pressure on joints.
○ Mobility: Turn q2h, ROM exercises, assist with transfers.
○ Communication: Aphasia management (speech therapy, picture boards).
Q6: Acute Kidney Injury – Fluid Balance
A client with acute kidney injury (AKI) has a 24-hour urine output of 300 mL. Which
intervention is priority for the practical nurse?
A. Encourage the client to drink 3 L of water daily
B. Monitor strict intake and output and notify the RN of oliguria [CORRECT]
C. Administer IV furosemide 40 mg as ordered
D. Measure abdominal girth every 4 hours
