BSN 266 Final Exam: Concepts of Nursing II
Updated and Verified Questions and Answers -
Nightingale College (Version 2)
1. A patient with Type 1 Diabetes presents with deep, rapid respirations and a
fruity breath odor. Which acid-base imbalance is likely present?
A. Respiratory Alkalosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Metabolic Acidosis
Answer: D
Explanation: Kussmaul respirations and fruity breath are classic signs of Diabetic
Ketoacidosis (DKA), which leads to metabolic acidosis due to the accumulation of ketones.
2. Which assessment finding is most characteristic of a patient with Left-Sided
Heart Failure?
A. Crackles in the lungs
B. Jugular venous distention
C. Peripheral edema
D. Ascites
Answer: A
Explanation: Left-sided heart failure causes pulmonary congestion, leading to symptoms
like crackles, shortness of breath, and cough.
,3. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which EKG
change should the nurse expect?
A. ST-segment depression
B. U-waves
C. Tall peaked T-waves
D. Flattened T-waves
Answer: C
Explanation: Hyperkalemia (K+ > 5.0) typically manifests on an EKG as tall, peaked T-
waves and potentially a widened QRS complex.
4. When administering Alterplase (tPA) to a patient with an ischemic stroke,
what is the most critical monitoring parameter?
A. Urine output
B. Neurological status and bleeding
C. Blood glucose
D. Serum potassium
Answer: B
Explanation: tPA is a thrombolytic with a high risk for intracranial hemorrhage; frequent
neuro checks and monitoring for bleeding are essential.
5. A patient has a suspected Tension Pneumothorax. Which clinical finding is a
late sign and requires immediate intervention?
A. Pleuritic chest pain
B. Tachycardia
C. Diminished lung sounds
D. Tracheal deviation
Answer: D
Explanation: Tracheal deviation to the unaffected side is a late and life-threatening sign of
a tension pneumothorax requiring needle decompression.
, 6. What is the primary goal of care for a patient in the emergent (resuscitative)
phase of a major burn?
A. Wound grafting
B. Physical therapy
C. Scar management
D. Fluid resuscitation and airway management
Answer: D
Explanation: The first 24-48 hours focus on maintaining an airway and preventing
hypovolemic shock through fluid replacement.
7. A patient with Chronic Renal Failure is receiving Epoetin Alfa. What is the
expected therapeutic outcome?
A. Decreased serum creatinine
B. Increased urine output
C. Increased red blood cell count
D. Decreased blood pressure
Answer: C
Explanation: Epoetin Alfa stimulates the bone marrow to produce red blood cells, which is
necessary because the kidneys no longer produce enough erythropoietin.
8. Which medication is the first-line treatment for a patient experiencing Status
Epilepticus?
A. Valproic Acid
B. Phenytoin
C. Lorazepam
D. Gabapentin
Answer: C
Explanation: Benzodiazepines like Lorazepam or Diazepam are the preferred rapid-acting
agents to stop active seizure activity.
Updated and Verified Questions and Answers -
Nightingale College (Version 2)
1. A patient with Type 1 Diabetes presents with deep, rapid respirations and a
fruity breath odor. Which acid-base imbalance is likely present?
A. Respiratory Alkalosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Metabolic Acidosis
Answer: D
Explanation: Kussmaul respirations and fruity breath are classic signs of Diabetic
Ketoacidosis (DKA), which leads to metabolic acidosis due to the accumulation of ketones.
2. Which assessment finding is most characteristic of a patient with Left-Sided
Heart Failure?
A. Crackles in the lungs
B. Jugular venous distention
C. Peripheral edema
D. Ascites
Answer: A
Explanation: Left-sided heart failure causes pulmonary congestion, leading to symptoms
like crackles, shortness of breath, and cough.
,3. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which EKG
change should the nurse expect?
A. ST-segment depression
B. U-waves
C. Tall peaked T-waves
D. Flattened T-waves
Answer: C
Explanation: Hyperkalemia (K+ > 5.0) typically manifests on an EKG as tall, peaked T-
waves and potentially a widened QRS complex.
4. When administering Alterplase (tPA) to a patient with an ischemic stroke,
what is the most critical monitoring parameter?
A. Urine output
B. Neurological status and bleeding
C. Blood glucose
D. Serum potassium
Answer: B
Explanation: tPA is a thrombolytic with a high risk for intracranial hemorrhage; frequent
neuro checks and monitoring for bleeding are essential.
5. A patient has a suspected Tension Pneumothorax. Which clinical finding is a
late sign and requires immediate intervention?
A. Pleuritic chest pain
B. Tachycardia
C. Diminished lung sounds
D. Tracheal deviation
Answer: D
Explanation: Tracheal deviation to the unaffected side is a late and life-threatening sign of
a tension pneumothorax requiring needle decompression.
, 6. What is the primary goal of care for a patient in the emergent (resuscitative)
phase of a major burn?
A. Wound grafting
B. Physical therapy
C. Scar management
D. Fluid resuscitation and airway management
Answer: D
Explanation: The first 24-48 hours focus on maintaining an airway and preventing
hypovolemic shock through fluid replacement.
7. A patient with Chronic Renal Failure is receiving Epoetin Alfa. What is the
expected therapeutic outcome?
A. Decreased serum creatinine
B. Increased urine output
C. Increased red blood cell count
D. Decreased blood pressure
Answer: C
Explanation: Epoetin Alfa stimulates the bone marrow to produce red blood cells, which is
necessary because the kidneys no longer produce enough erythropoietin.
8. Which medication is the first-line treatment for a patient experiencing Status
Epilepticus?
A. Valproic Acid
B. Phenytoin
C. Lorazepam
D. Gabapentin
Answer: C
Explanation: Benzodiazepines like Lorazepam or Diazepam are the preferred rapid-acting
agents to stop active seizure activity.
