NUR 355 Exam 4: 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 clinical finding is most expected?
A. Peripheral edema
B. Crackles in the lungs
C. Jugular venous distention
D. Hepatosplenomegaly
Ans: B
Explanation: Left-sided heart failure leads to pulmonary congestion because the left ventricle cannot
pump blood forward effectively. This results in fluid backing up into the lungs, manifesting as crackles or
wheezing. In contrast, peripheral edema and jugular venous distention are primary indicators of right-
sided heart failure. The nurse must prioritize respiratory assessments to identify potential pulmonary
edema early. Proper management involves the use of diuretics and supplemental oxygen to improve
patient outcomes.
2. Which laboratory value is most indicative of a myocardial infarction?
A. B-type natriuretic peptide (BNP)
B. Serum potassium
C. Troponin T
D. Creatinine kinase-MB (CK-MB)
Ans: C
,Explanation: Troponin levels are the most specific biomarkers for identifying cardiac muscle injury and
myocardial infarction. While CK-MB is also used, it returns to normal faster and is less specific than
troponin. BNP is primarily used to assess the severity of heart failure rather than an acute MI. Nurses
must monitor these levels closely to determine the extent of myocardial damage. Prompt identification of
elevated troponin allows for rapid intervention in the emergency setting.
3. A patient is diagnosed with Chronic Obstructive Pulmonary Disease (COPD). What is the primary goal of
pursed-lip breathing?
A. To increase the respiratory rate
B. To decrease oxygen saturation
C. To promote carbon dioxide elimination
D. To strengthen the intercostal muscles
Ans: C
Explanation: Pursed-lip breathing helps to maintain positive airway pressure during exhalation in COPD
patients. This technique prevents the collapse of small airways and facilitates the removal of trapped
carbon dioxide. It effectively slows the breathing rate and reduces the work of breathing for the
individual. Nurses should teach this technique to improve gas exchange and reduce shortness of breath.
Consistent practice can significantly enhance the patient’s exercise tolerance and quality of life.
4. A nurse is caring for a patient in Diabetic Ketoacidosis (DKA). Which acid-base imbalance is expected?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis
, Ans: D
Explanation: Diabetic ketoacidosis occurs when the body breaks down fats for energy, producing an
excess of ketones. These ketones are acidic, leading to a decrease in blood pH and metabolic acidosis. The
body may attempt to compensate through Kussmaul respirations to blow off carbon dioxide.
Understanding this mechanism is vital for monitoring blood gas results and electrolyte levels. Treatment
focuses on fluid resuscitation and insulin therapy to reverse the ketotic state.
5. What is the first priority for a patient presenting with an acute ischemic stroke within the 3-hour
window?
A. Obtain a CT scan of the head
B. Initiate physical therapy
C. Perform a carotid ultrasound
D. Administer oral aspirin
Ans: A
Explanation: A non-contrast CT scan is the essential first step to rule out a hemorrhagic stroke before
starting treatment. If the stroke is confirmed as ischemic, thrombolytic therapy like tPA may be
administered if criteria are met. Time is a critical factor in saving brain tissue during an acute
cerebrovascular event. Nursing interventions include monitoring neurological status and maintaining a
stable blood pressure. Rapid diagnosis ensures the patient receives the most appropriate and life-saving
interventions.
6. A patient with a history of atrial fibrillation is prescribed warfarin. Which lab result should the nurse
monitor?
A. Activated partial thromboplastin time (aPTT)
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 clinical finding is most expected?
A. Peripheral edema
B. Crackles in the lungs
C. Jugular venous distention
D. Hepatosplenomegaly
Ans: B
Explanation: Left-sided heart failure leads to pulmonary congestion because the left ventricle cannot
pump blood forward effectively. This results in fluid backing up into the lungs, manifesting as crackles or
wheezing. In contrast, peripheral edema and jugular venous distention are primary indicators of right-
sided heart failure. The nurse must prioritize respiratory assessments to identify potential pulmonary
edema early. Proper management involves the use of diuretics and supplemental oxygen to improve
patient outcomes.
2. Which laboratory value is most indicative of a myocardial infarction?
A. B-type natriuretic peptide (BNP)
B. Serum potassium
C. Troponin T
D. Creatinine kinase-MB (CK-MB)
Ans: C
,Explanation: Troponin levels are the most specific biomarkers for identifying cardiac muscle injury and
myocardial infarction. While CK-MB is also used, it returns to normal faster and is less specific than
troponin. BNP is primarily used to assess the severity of heart failure rather than an acute MI. Nurses
must monitor these levels closely to determine the extent of myocardial damage. Prompt identification of
elevated troponin allows for rapid intervention in the emergency setting.
3. A patient is diagnosed with Chronic Obstructive Pulmonary Disease (COPD). What is the primary goal of
pursed-lip breathing?
A. To increase the respiratory rate
B. To decrease oxygen saturation
C. To promote carbon dioxide elimination
D. To strengthen the intercostal muscles
Ans: C
Explanation: Pursed-lip breathing helps to maintain positive airway pressure during exhalation in COPD
patients. This technique prevents the collapse of small airways and facilitates the removal of trapped
carbon dioxide. It effectively slows the breathing rate and reduces the work of breathing for the
individual. Nurses should teach this technique to improve gas exchange and reduce shortness of breath.
Consistent practice can significantly enhance the patient’s exercise tolerance and quality of life.
4. A nurse is caring for a patient in Diabetic Ketoacidosis (DKA). Which acid-base imbalance is expected?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis
, Ans: D
Explanation: Diabetic ketoacidosis occurs when the body breaks down fats for energy, producing an
excess of ketones. These ketones are acidic, leading to a decrease in blood pH and metabolic acidosis. The
body may attempt to compensate through Kussmaul respirations to blow off carbon dioxide.
Understanding this mechanism is vital for monitoring blood gas results and electrolyte levels. Treatment
focuses on fluid resuscitation and insulin therapy to reverse the ketotic state.
5. What is the first priority for a patient presenting with an acute ischemic stroke within the 3-hour
window?
A. Obtain a CT scan of the head
B. Initiate physical therapy
C. Perform a carotid ultrasound
D. Administer oral aspirin
Ans: A
Explanation: A non-contrast CT scan is the essential first step to rule out a hemorrhagic stroke before
starting treatment. If the stroke is confirmed as ischemic, thrombolytic therapy like tPA may be
administered if criteria are met. Time is a critical factor in saving brain tissue during an acute
cerebrovascular event. Nursing interventions include monitoring neurological status and maintaining a
stable blood pressure. Rapid diagnosis ensures the patient receives the most appropriate and life-saving
interventions.
6. A patient with a history of atrial fibrillation is prescribed warfarin. Which lab result should the nurse
monitor?
A. Activated partial thromboplastin time (aPTT)
