BSN 266 Final Exam: Concepts of Nursing II
Updated and Verified Questions and Answers -
Nightingale College (Version 3)
1. A nurse is caring for a client with heart failure who is prescribed furosemide.
Which laboratory value should the nurse monitor most closely?
A. Serum potassium
B. Serum sodium
C. Serum calcium
D. Serum glucose
Answer: A
Explanation: Furosemide is a loop diuretic that can lead to significant potassium loss;
monitoring for hypokalemia is a priority.
2. When assessing a patient with a suspected deep vein thrombosis (DVT),
which clinical manifestation should the nurse anticipate?
A. Bilateral calf edema
B. Unilateral leg swelling and warmth
C. Cool, pale extremity
D. Diminished pedal pulses
Answer: B
Explanation: DVT typically presents with unilateral swelling, redness, and warmth in the
affected extremity.
,3. Which arterial blood gas (ABG) result is consistent with a patient experiencing
an acute asthma attack and hyperventilating?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.50, PaCO2 30, HCO3 22
C. pH 7.32, PaCO2 40, HCO3 18
D. pH 7.48, PaCO2 45, HCO3 30
Answer: B
Explanation: Hyperventilation causes excessive loss of CO2, leading to respiratory
alkalosis (high pH and low PaCO2).
4. A nurse is teaching a patient with Type 1 Diabetes about exercise. Which
instruction should be included?
A. Inject insulin into the muscle group being exercised
B. Exercise only when insulin is at its peak action
C. Decrease carbohydrate intake before strenuous activity
D. Avoid exercise if blood glucose is less than 100 mg/dL
Answer: D
Explanation: Exercise should be avoided if blood glucose is low to prevent hypoglycemia;
a snack should be consumed if glucose is below 100 mg/dL.
5. In a patient with chronic obstructive pulmonary disease (COPD), the nurse
understands that the drive to breathe is triggered by:
A. High carbon dioxide levels
B. High serum pH
C. Low oxygen levels
D. Low bicarbonate levels
Answer: C
Explanation: In chronic CO2 retainers like COPD patients, the chemoreceptors become
insensitive to CO2, and hypoxemia becomes the primary stimulus for breathing.
, 6. Which assessment finding requires immediate intervention for a patient 2
hours post-thyroidectomy?
A. Sore throat when speaking
B. Laryngeal stridor
C. Pain level of 4 out of 10
D. Dressings with small amount of serosanguinous drainage
Answer: B
Explanation: Laryngeal stridor indicates airway obstruction, which is a life-threatening
emergency post-thyroid surgery.
7. A client is admitted with a diagnosis of diverticulitis. Which diet should the
nurse expect to be ordered during the acute phase?
A. NPO or clear liquids
B. Full liquid diet
C. High fiber diet
D. Mechanical soft diet
Answer: A
Explanation: During acute diverticulitis, the bowel needs rest; therefore, NPO or clear
liquids are typically prescribed until inflammation subsides.
8. A nurse is preparing to administer digoxin to a client. Which action is most
important before administration?
A. Check the blood pressure
B. Review the patient’s sodium levels
C. Monitor the respiratory rate
D. Assess the apical pulse for 60 seconds
Answer: D
Explanation: Digoxin should be withheld if the apical heart rate is below 60 bpm to
prevent worsening bradycardia.
Updated and Verified Questions and Answers -
Nightingale College (Version 3)
1. A nurse is caring for a client with heart failure who is prescribed furosemide.
Which laboratory value should the nurse monitor most closely?
A. Serum potassium
B. Serum sodium
C. Serum calcium
D. Serum glucose
Answer: A
Explanation: Furosemide is a loop diuretic that can lead to significant potassium loss;
monitoring for hypokalemia is a priority.
2. When assessing a patient with a suspected deep vein thrombosis (DVT),
which clinical manifestation should the nurse anticipate?
A. Bilateral calf edema
B. Unilateral leg swelling and warmth
C. Cool, pale extremity
D. Diminished pedal pulses
Answer: B
Explanation: DVT typically presents with unilateral swelling, redness, and warmth in the
affected extremity.
,3. Which arterial blood gas (ABG) result is consistent with a patient experiencing
an acute asthma attack and hyperventilating?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.50, PaCO2 30, HCO3 22
C. pH 7.32, PaCO2 40, HCO3 18
D. pH 7.48, PaCO2 45, HCO3 30
Answer: B
Explanation: Hyperventilation causes excessive loss of CO2, leading to respiratory
alkalosis (high pH and low PaCO2).
4. A nurse is teaching a patient with Type 1 Diabetes about exercise. Which
instruction should be included?
A. Inject insulin into the muscle group being exercised
B. Exercise only when insulin is at its peak action
C. Decrease carbohydrate intake before strenuous activity
D. Avoid exercise if blood glucose is less than 100 mg/dL
Answer: D
Explanation: Exercise should be avoided if blood glucose is low to prevent hypoglycemia;
a snack should be consumed if glucose is below 100 mg/dL.
5. In a patient with chronic obstructive pulmonary disease (COPD), the nurse
understands that the drive to breathe is triggered by:
A. High carbon dioxide levels
B. High serum pH
C. Low oxygen levels
D. Low bicarbonate levels
Answer: C
Explanation: In chronic CO2 retainers like COPD patients, the chemoreceptors become
insensitive to CO2, and hypoxemia becomes the primary stimulus for breathing.
, 6. Which assessment finding requires immediate intervention for a patient 2
hours post-thyroidectomy?
A. Sore throat when speaking
B. Laryngeal stridor
C. Pain level of 4 out of 10
D. Dressings with small amount of serosanguinous drainage
Answer: B
Explanation: Laryngeal stridor indicates airway obstruction, which is a life-threatening
emergency post-thyroid surgery.
7. A client is admitted with a diagnosis of diverticulitis. Which diet should the
nurse expect to be ordered during the acute phase?
A. NPO or clear liquids
B. Full liquid diet
C. High fiber diet
D. Mechanical soft diet
Answer: A
Explanation: During acute diverticulitis, the bowel needs rest; therefore, NPO or clear
liquids are typically prescribed until inflammation subsides.
8. A nurse is preparing to administer digoxin to a client. Which action is most
important before administration?
A. Check the blood pressure
B. Review the patient’s sodium levels
C. Monitor the respiratory rate
D. Assess the apical pulse for 60 seconds
Answer: D
Explanation: Digoxin should be withheld if the apical heart rate is below 60 bpm to
prevent worsening bradycardia.
