NUR 355 Final Exam: Acute & Chronic Health Disruptions
In Adults I V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A nurse is caring for a patient who is 24 hours post-myocardial infarction and suddenly develops a heart
rate of 120 bpm and crackles in the lung bases. Which complication should the nurse suspect first?
A. Pulmonary embolism
B. Cardiac tamponade
C. Pericarditis
D. Heart failure
Ans: D
Explanation: The development of crackles and tachycardia post-myocardial infarction is a classic
indicator of acute left-sided heart failure. This occurs when the damaged myocardium cannot pump
blood effectively, leading to pulmonary congestion. Tachycardia is a compensatory mechanism to
maintain cardiac output in the face of decreased stroke volume. Pericarditis typically presents with chest
pain and a friction rub rather than pulmonary crackles. Monitoring for these signs allows the nurse to
intervene early with diuretics or inotropic support to prevent pulmonary edema.
2. Which assessment finding should the nurse prioritize for a patient admitted with an acute exacerbation
of Chronic Obstructive Pulmonary Disease (COPD)?
A. Productive cough with thick green sputum
B. Clubbing of the fingernails
C. Pursed-lip breathing during rest
D. Increased use of accessory muscles
,Ans: D
Explanation: The use of accessory muscles indicates a significant increase in the work of breathing and
impending respiratory failure. While clubbing and pursed-lip breathing are common chronic findings in
COPD, they do not indicate acute distress. Sputum changes suggest infection but are not as immediately
life-threatening as respiratory exhaustion. The nurse must assess the patient’s ventilation status and
prepare for possible non-invasive positive pressure ventilation. Prioritizing the work of breathing follows
the ABC framework for emergency nursing care.
3. A patient with Type 1 Diabetes Mellitus presents to the ED with a blood glucose of 550 mg/dL and
Kussmaul respirations. What is the nurse’s immediate priority intervention?
A. Administering subcutaneous Lantus insulin
B. Providing a carbohydrate-rich snack
C. Starting an IV infusion of 0.9% Normal Saline
D. Assessing for signs of hypoglycemia
Ans: C
Explanation: In Diabetic Ketoacidosis (DKA), the patient is severely dehydrated due to osmotic diuresis
caused by hyperglycemia. Rehydrating the patient with isotonic fluids is the first step to restore
circulatory volume and stabilize the blood pressure. Insulin therapy is necessary but should follow or
accompany fluid resuscitation to prevent cardiovascular collapse. Kussmaul respirations are a
compensatory mechanism for metabolic acidosis, which will improve as the underlying fluid and
electrolyte imbalances are corrected. Continuous monitoring of electrolytes like potassium is also vital
during this initial phase.
, 4. A nurse is reviewing the lab results of a patient with Chronic Kidney Disease (CKD) and notes a potassium
level of 6.5 mEq/L. Which action is most critical?
A. Checking the patient’s blood pressure
B. Obtaining a 12-lead Electrocardiogram (ECG)
C. Encouraging a low-potassium diet
D. Administering a scheduled dose of Lisinopril
Ans: B
Explanation: Hyperkalemia at levels above 6.0 mEq/L poses a severe risk for lethal cardiac arrhythmias.
An ECG must be performed immediately to look for peaked T-waves, widened QRS complexes, or the loss
of P-waves. Lisinopril should actually be held as it can further increase potassium levels in CKD patients.
Dietary changes are long-term management strategies and are insufficient for treating an acute, life-
threatening elevation. Stabilizing the cardiac membrane and lowering serum potassium are the
immediate clinical goals.
5. Which clinical manifestation should a nurse monitor for in a patient with suspected Hyperthyroidism
(Graves’ Disease)?
A. Weight gain and bradycardia
B. Cold intolerance and dry skin
C. Exophthalmos and tremors
D. Periorbital edema and thick tongue
Ans: C
Explanation: Hyperthyroidism results in a hypermetabolic state characterized by heat intolerance,
weight loss, and tremors. Exophthalmos, or bulging eyes, is a specific autoimmune manifestation found in
In Adults I V3 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A nurse is caring for a patient who is 24 hours post-myocardial infarction and suddenly develops a heart
rate of 120 bpm and crackles in the lung bases. Which complication should the nurse suspect first?
A. Pulmonary embolism
B. Cardiac tamponade
C. Pericarditis
D. Heart failure
Ans: D
Explanation: The development of crackles and tachycardia post-myocardial infarction is a classic
indicator of acute left-sided heart failure. This occurs when the damaged myocardium cannot pump
blood effectively, leading to pulmonary congestion. Tachycardia is a compensatory mechanism to
maintain cardiac output in the face of decreased stroke volume. Pericarditis typically presents with chest
pain and a friction rub rather than pulmonary crackles. Monitoring for these signs allows the nurse to
intervene early with diuretics or inotropic support to prevent pulmonary edema.
2. Which assessment finding should the nurse prioritize for a patient admitted with an acute exacerbation
of Chronic Obstructive Pulmonary Disease (COPD)?
A. Productive cough with thick green sputum
B. Clubbing of the fingernails
C. Pursed-lip breathing during rest
D. Increased use of accessory muscles
,Ans: D
Explanation: The use of accessory muscles indicates a significant increase in the work of breathing and
impending respiratory failure. While clubbing and pursed-lip breathing are common chronic findings in
COPD, they do not indicate acute distress. Sputum changes suggest infection but are not as immediately
life-threatening as respiratory exhaustion. The nurse must assess the patient’s ventilation status and
prepare for possible non-invasive positive pressure ventilation. Prioritizing the work of breathing follows
the ABC framework for emergency nursing care.
3. A patient with Type 1 Diabetes Mellitus presents to the ED with a blood glucose of 550 mg/dL and
Kussmaul respirations. What is the nurse’s immediate priority intervention?
A. Administering subcutaneous Lantus insulin
B. Providing a carbohydrate-rich snack
C. Starting an IV infusion of 0.9% Normal Saline
D. Assessing for signs of hypoglycemia
Ans: C
Explanation: In Diabetic Ketoacidosis (DKA), the patient is severely dehydrated due to osmotic diuresis
caused by hyperglycemia. Rehydrating the patient with isotonic fluids is the first step to restore
circulatory volume and stabilize the blood pressure. Insulin therapy is necessary but should follow or
accompany fluid resuscitation to prevent cardiovascular collapse. Kussmaul respirations are a
compensatory mechanism for metabolic acidosis, which will improve as the underlying fluid and
electrolyte imbalances are corrected. Continuous monitoring of electrolytes like potassium is also vital
during this initial phase.
, 4. A nurse is reviewing the lab results of a patient with Chronic Kidney Disease (CKD) and notes a potassium
level of 6.5 mEq/L. Which action is most critical?
A. Checking the patient’s blood pressure
B. Obtaining a 12-lead Electrocardiogram (ECG)
C. Encouraging a low-potassium diet
D. Administering a scheduled dose of Lisinopril
Ans: B
Explanation: Hyperkalemia at levels above 6.0 mEq/L poses a severe risk for lethal cardiac arrhythmias.
An ECG must be performed immediately to look for peaked T-waves, widened QRS complexes, or the loss
of P-waves. Lisinopril should actually be held as it can further increase potassium levels in CKD patients.
Dietary changes are long-term management strategies and are insufficient for treating an acute, life-
threatening elevation. Stabilizing the cardiac membrane and lowering serum potassium are the
immediate clinical goals.
5. Which clinical manifestation should a nurse monitor for in a patient with suspected Hyperthyroidism
(Graves’ Disease)?
A. Weight gain and bradycardia
B. Cold intolerance and dry skin
C. Exophthalmos and tremors
D. Periorbital edema and thick tongue
Ans: C
Explanation: Hyperthyroidism results in a hypermetabolic state characterized by heat intolerance,
weight loss, and tremors. Exophthalmos, or bulging eyes, is a specific autoimmune manifestation found in
