NUR 355 Exam 2: Acute & Chronic Health Disruptions In
Adults I V2 - Arizona College Updated and Latest Questions
and Correct Answers with Rationale
1. A nurse is assessing a patient with left-sided heart failure. Which of the following findings should the
nurse expect?
A. Jugular venous distention
B. Hepatomegaly
C. Peripheral edema
D. Crackles in the lungs
Ans: D
Explanation: Left-sided heart failure results in pulmonary congestion because the left ventricle cannot
pump blood efficiently into the systemic circulation. This backflow causes fluid to accumulate in the
alveoli, resulting in crackles and dyspnea. Findings like jugular venous distention and peripheral edema
are characteristic of right-sided heart failure. The nurse must prioritize respiratory assessment to
monitor for worsening pulmonary edema. Timely intervention with diuretics can help reduce the fluid
volume and improve gas exchange.
2. A patient with a history of COPD is receiving oxygen therapy. What is the most important reason to
maintain oxygen saturation between 88% and 92%?
A. To avoid suppressing the hypoxic drive
B. To prevent oxygen toxicity
C. To reduce the risk of pneumonia
D. To increase hemoglobin affinity
,Ans: A
Explanation: In patients with chronic hypercapnia, the respiratory drive is often triggered by low oxygen
levels rather than high carbon dioxide. Providing excessive supplemental oxygen can satisfy this hypoxic
drive and lead to respiratory depression or arrest. Maintaining a lower but safe saturation range prevents
this complication while ensuring adequate tissue perfusion. The nurse should use a Venturi mask for
precise oxygen delivery to these patients. Monitoring arterial blood gases is essential to evaluate the
patient’s acid-base balance during therapy.
3. An adult patient’s ABG results are pH 7.31, PaCO2 52 mmHg, and HCO3 25 mEq/L. How should the nurse
interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Ans: A
Explanation: The pH level of 7.31 indicates acidosis, while the elevated PaCO2 indicates a respiratory
cause for the imbalance. Because the bicarbonate level is within the normal range, the condition is
categorized as uncompensated respiratory acidosis. This state is common in patients with
hypoventilation or obstructive lung diseases like COPD. Nursing interventions should focus on improving
ventilation and clearing the airway of secretions. Serial blood gas monitoring is necessary to track the
patient’s response to treatment.
4. Which medication is considered the ‘gold standard’ for the immediate relief of acute bronchospasm in an
asthma patient?
A. Salmeterol
, B. Fluticasone
C. Albuterol
D. Montelukast
Ans: C
Explanation: Albuterol is a short-acting beta-2 agonist that works rapidly to dilate the bronchioles
during an acute asthma attack. It is classified as a rescue medication and is not intended for long-term
maintenance. In contrast, Salmeterol is a long-acting agonist used for daily control rather than acute
symptoms. Fluticasone is a corticosteroid used to reduce inflammation over time rather than providing
immediate relief. Patients should be taught to always carry their rescue inhaler for emergency use.
5. A patient with type 1 diabetes is found unconscious and diaphoretic. What is the nurse’s priority action?
A. Administer 50% Dextrose IV
B. Check the blood glucose level
C. Administer regular insulin
D. Provide an oral carbohydrate snack
Ans: A
Explanation: Hypoglycemia is a life-threatening emergency that requires immediate correction of blood
glucose levels to prevent brain damage. When a patient is unconscious and cannot safely swallow,
intravenous dextrose is the fastest and safest route for treatment. Checking the glucose level is important,
but if the patient is symptomatic and unresponsive, treatment should not be delayed. Glucagon can also
be administered if intravenous access is not readily available. After the patient regains consciousness, a
complex carbohydrate should be provided to maintain stability.
Adults I V2 - Arizona College Updated and Latest Questions
and Correct Answers with Rationale
1. A nurse is assessing a patient with left-sided heart failure. Which of the following findings should the
nurse expect?
A. Jugular venous distention
B. Hepatomegaly
C. Peripheral edema
D. Crackles in the lungs
Ans: D
Explanation: Left-sided heart failure results in pulmonary congestion because the left ventricle cannot
pump blood efficiently into the systemic circulation. This backflow causes fluid to accumulate in the
alveoli, resulting in crackles and dyspnea. Findings like jugular venous distention and peripheral edema
are characteristic of right-sided heart failure. The nurse must prioritize respiratory assessment to
monitor for worsening pulmonary edema. Timely intervention with diuretics can help reduce the fluid
volume and improve gas exchange.
2. A patient with a history of COPD is receiving oxygen therapy. What is the most important reason to
maintain oxygen saturation between 88% and 92%?
A. To avoid suppressing the hypoxic drive
B. To prevent oxygen toxicity
C. To reduce the risk of pneumonia
D. To increase hemoglobin affinity
,Ans: A
Explanation: In patients with chronic hypercapnia, the respiratory drive is often triggered by low oxygen
levels rather than high carbon dioxide. Providing excessive supplemental oxygen can satisfy this hypoxic
drive and lead to respiratory depression or arrest. Maintaining a lower but safe saturation range prevents
this complication while ensuring adequate tissue perfusion. The nurse should use a Venturi mask for
precise oxygen delivery to these patients. Monitoring arterial blood gases is essential to evaluate the
patient’s acid-base balance during therapy.
3. An adult patient’s ABG results are pH 7.31, PaCO2 52 mmHg, and HCO3 25 mEq/L. How should the nurse
interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Ans: A
Explanation: The pH level of 7.31 indicates acidosis, while the elevated PaCO2 indicates a respiratory
cause for the imbalance. Because the bicarbonate level is within the normal range, the condition is
categorized as uncompensated respiratory acidosis. This state is common in patients with
hypoventilation or obstructive lung diseases like COPD. Nursing interventions should focus on improving
ventilation and clearing the airway of secretions. Serial blood gas monitoring is necessary to track the
patient’s response to treatment.
4. Which medication is considered the ‘gold standard’ for the immediate relief of acute bronchospasm in an
asthma patient?
A. Salmeterol
, B. Fluticasone
C. Albuterol
D. Montelukast
Ans: C
Explanation: Albuterol is a short-acting beta-2 agonist that works rapidly to dilate the bronchioles
during an acute asthma attack. It is classified as a rescue medication and is not intended for long-term
maintenance. In contrast, Salmeterol is a long-acting agonist used for daily control rather than acute
symptoms. Fluticasone is a corticosteroid used to reduce inflammation over time rather than providing
immediate relief. Patients should be taught to always carry their rescue inhaler for emergency use.
5. A patient with type 1 diabetes is found unconscious and diaphoretic. What is the nurse’s priority action?
A. Administer 50% Dextrose IV
B. Check the blood glucose level
C. Administer regular insulin
D. Provide an oral carbohydrate snack
Ans: A
Explanation: Hypoglycemia is a life-threatening emergency that requires immediate correction of blood
glucose levels to prevent brain damage. When a patient is unconscious and cannot safely swallow,
intravenous dextrose is the fastest and safest route for treatment. Checking the glucose level is important,
but if the patient is symptomatic and unresponsive, treatment should not be delayed. Glucagon can also
be administered if intravenous access is not readily available. After the patient regains consciousness, a
complex carbohydrate should be provided to maintain stability.
