Keiser University
Course Code: NUR1211C
Course Title: Basic Adult Healthcare
Credit Hours:8.0
Exam: Final Exam
Date:2026
A 67-year-old man with a 45-pack-year smoking history presents to the emergency department
with progressive dyspnea, barrel chest, and use of accessory muscles. His ABG results
show pH 7.32, PaCO2 58 mmHg, PaO2 54 mmHg, HCO3 30 mEq/L, and SpO2 86%. The
nurse correctly identifies this acid-base disturbance as:
A. Respiratory alkalosis with metabolic compensation B. Metabolic acidosis with respiratory
compensation C. Respiratory acidosis with metabolic compensation D. Mixed metabolic and
respiratory acidosis
Correct Answer: C
Rationale: The low pH (7.32) confirms acidosis. The elevated PaCO2 (58 mmHg) identifies the
primary problem as respiratory acidosis caused by hypoventilation and CO2 retention,
consistent with severe COPD/emphysema. The elevated bicarbonate (30 mEq/L, normal 22-26
mEq/L) represents renal compensation, where the kidneys retain bicarbonate over days to
weeks to buffer the chronic acid load. This is a chronic, compensated respiratory acidosis. The
nurse must administer controlled, low-flow oxygen (typically 1-2 L/min via nasal cannula)
because COPD patients may rely on hypoxic drive for ventilation. Aggressive oxygen
supplementation can suppress the hypoxic drive and precipitate respiratory failure.
A 58-year-old woman is admitted following a massive pulmonary embolism. She is hypotensive
(BP 82/50 mmHg), tachycardic (HR 128 bpm), and her neck veins are markedly
distended. Her chest X-ray is clear, and her ECG shows a new S1Q3T3 pattern. The
nurse anticipates which hemodynamic change as the primary pathophysiological
mechanism causing her hypotension?
A. Left ventricular failure causing reduced cardiac output B. Acute right ventricular strain causing
reduced pulmonary blood flow and decreased left ventricular preload C. Systemic vasodilation
caused by inflammatory mediator release D. Pericardial tamponade causing compression of all
cardiac chambers
Correct Answer: B
Rationale: A massive pulmonary embolism obstructs pulmonary arterial flow, causing acute right
ventricular pressure overload and strain. The right ventricle dilates and fails, reducing the
amount of blood traversing the pulmonary circulation to reach the left side of the heart. This
dramatically decreases left ventricular preload and consequently stroke volume and cardiac
output, causing obstructive shock. Jugular venous distension reflects the backed-up right-sided
1
, pressure. The S1Q3T3 pattern on ECG (deep S wave in lead I, Q wave and T wave inversion in
lead III) is a classic but non-specific sign of acute right heart strain. Management priorities
include anticoagulation, systemic thrombolytics if hemodynamically unstable, and possibly
catheter-directed therapy or surgical embolectomy.
A 72-year-old woman with a history of hypertension and type 2 diabetes is brought to the ED by
her daughter, who states her mother has been "confused and not acting herself" for the
past 6 hours. On assessment, the patient scores 13 on the Glasgow Coma Scale, is oriented
only to person, has right-sided facial droop, and arm drift. Her blood pressure is 188/102
mmHg. CT scan of the head is negative for hemorrhage. The thrombolytic therapy
window has not been exceeded. The nurse prepares for alteplase (tPA) administration and
is aware that a contraindication to tPA in ischemic stroke includes:
A. Age greater than 65 years B. Blood pressure of 188/102 mmHg before treatment C. Blood glucose
below 50 mg/dL or above 400 mg/dL D. Presence of right-sided deficits only
Correct Answer: C
Rationale: Hypoglycemia (glucose below 50 mg/dL) is a critical contraindication to tPA because it can
mimic ischemic stroke and is immediately reversible; administering tPA unnecessarily carries
serious hemorrhagic risk. Hyperglycemia above 400 mg/dL is also a relative contraindication.
Age alone is not a contraindication to tPA in eligible patients. Blood pressure of 188/102
mmHg must be controlled to below 185/110 mmHg before tPA administration and maintained
below 180/105 mmHg during and after infusion, but is not an absolute contraindication if
controllable. The nurse must ensure blood glucose is checked, BP is managed (typically with IV
labetalol or nicardipine), and informed consent is obtained before administration.
A 55-year-old man with no prior cardiac history is admitted with crushing chest pain radiating
to the left jaw and arm, diaphoresis, and nausea for the past 90 minutes. His 12-lead ECG
shows ST elevation in leads II, III, and aVF. The nurse recognizes this pattern as
indicative of:
A. Anterior STEMI involving the left anterior descending artery B. Lateral STEMI involving the left
circumflex artery C. Inferior STEMI involving the right coronary artery D. Posterior STEMI
requiring additional leads to confirm
Correct Answer: C
Rationale: ST elevation in the inferior leads (II, III, and aVF) classically represents an inferior wall
STEMI, most commonly caused by occlusion of the right coronary artery (RCA), which supplies
the inferior wall of the left ventricle, the right ventricle, and the SA and AV nodes in most
patients. This distinction is clinically critical because inferior STEMIs are frequently
associated with right ventricular infarction (present in up to 40% of cases), requiring the nurse
to obtain right-sided leads (V4R), avoid nitrates (which reduce preload and can cause severe
hypotension in RV infarction), and administer IV fluid challenges instead. The nurse must
activate the cardiac catheterization lab immediately, targeting door-to-balloon time within 90
minutes.
A 48-year-old woman undergoes a total thyroidectomy for thyroid cancer. Six hours
postoperatively, she reports tingling and numbness around her mouth and in her
fingertips. The nurse assesses for Chvostek's sign by tapping the facial nerve and observes
twitching of the facial muscles. The nurse's priority action is to:
A. Reassure the patient that this is expected postoperative anxiety B. Assess serum calcium
immediately and prepare for IV calcium gluconate administration C. Administer oral calcium
carbonate tablets and observe for 24 hours D. Check serum potassium, as hypokalemia causes
identical symptoms
2
, Correct Answer: B
Rationale: Total thyroidectomy carries the risk of inadvertent removal or devascularization of all four
parathyroid glands, which lie in close proximity to the thyroid. Loss of parathyroid function
causes acute hypoparathyroidism, resulting in hypocalcemia, which typically manifests within
24-48 hours postoperatively. Circumoral numbness, fingertip tingling, positive Chvostek's sign
(facial nerve twitching), and Trousseau's sign (carpal spasm with BP cuff inflation) are
hallmarks of hypocalcemic tetany. Untreated hypocalcemia progresses to laryngospasm,
bronchospasm, seizures, and fatal cardiac arrhythmias. IV calcium gluconate is the immediate
treatment for symptomatic hypocalcemia, followed by ongoing monitoring, oral calcium, and
vitamin D supplementation.
A 63-year-old man with known cirrhosis of the liver presents with acute confusion, asterixis
(flapping tremor), and increasing abdominal girth. His ammonia level is 148 mcmol/L
(normal less than 35 mcmol/L). The physician orders lactulose 30 mL orally three times
daily. The nurse correctly explains the mechanism of lactulose to the student nurse as:
A. Lactulose directly binds ammonia in the bloodstream, removing it from circulation B. Lactulose
acidifies colonic contents, trapping ammonia as ammonium ion and promoting its excretion in
stool while also functioning as an osmotic laxative C. Lactulose stimulates the liver to
metabolize ammonia through the urea cycle D. Lactulose reduces ammonia production by
killing ammonia-producing gut bacteria directly
Correct Answer: B
Rationale: Lactulose is a synthetic, non-absorbable disaccharide metabolized by colonic bacteria into
organic acids (primarily lactic and acetic acid). This acidifies the colonic lumen, lowering pH
to approximately 5-6. At this acidic pH, ammonia (NH3), which freely crosses cell membranes,
is converted to the ammonium ion (NH4+), which is ionized and cannot be absorbed back into
the portal circulation. Additionally, the osmotic effect of lactulose causes diarrhea, physically
expelling ammonium-laden stool. The target is 2-4 soft stools per day. Rifaximin, a non-
absorbable antibiotic, is often added to reduce ammonia-producing bacteria. The nurse must
monitor for excessive diarrhea causing electrolyte imbalances and dehydration.
A 76-year-old woman is brought to the ED following a fall. She is alert and oriented but reports
severe left hip pain and inability to bear weight. On assessment, the nurse observes that
her left leg is shortened, externally rotated, and adducted. X-ray confirms a displaced
femoral neck fracture. The nurse recognizes that this patient's highest postoperative
priority concern, beyond pain management, is prevention of:
A. Wound dehiscence and surgical site infection B. Venous thromboembolism and fat embolism
syndrome C. Postoperative pneumonia only D. Urinary tract infection from prolonged
catheterization
Correct Answer: B
Rationale: Hip fractures and subsequent surgical repair (hemiarthroplasty or total hip arthroplasty)
carry extremely high risks of venous thromboembolism (DVT and pulmonary embolism), which
is among the leading causes of postoperative mortality in this population. Fat embolism
syndrome (FES) can occur when fatty marrow enters the venous circulation during fracture
manipulation or reaming, causing the classic triad of hypoxemia, neurological changes, and
petechial rash, typically within 24-72 hours postoperatively. VTE prophylaxis (LMWH,
fondaparinux, or rivaroxaban), early mobilization, compression stockings, and pneumatic
sequential compression devices are essential. All other complications listed are important but
carry comparatively lower mortality risk in this specific scenario.
A 34-year-old woman at 32 weeks gestation is admitted with blood pressure of 156/104 mmHg on
3
Course Code: NUR1211C
Course Title: Basic Adult Healthcare
Credit Hours:8.0
Exam: Final Exam
Date:2026
A 67-year-old man with a 45-pack-year smoking history presents to the emergency department
with progressive dyspnea, barrel chest, and use of accessory muscles. His ABG results
show pH 7.32, PaCO2 58 mmHg, PaO2 54 mmHg, HCO3 30 mEq/L, and SpO2 86%. The
nurse correctly identifies this acid-base disturbance as:
A. Respiratory alkalosis with metabolic compensation B. Metabolic acidosis with respiratory
compensation C. Respiratory acidosis with metabolic compensation D. Mixed metabolic and
respiratory acidosis
Correct Answer: C
Rationale: The low pH (7.32) confirms acidosis. The elevated PaCO2 (58 mmHg) identifies the
primary problem as respiratory acidosis caused by hypoventilation and CO2 retention,
consistent with severe COPD/emphysema. The elevated bicarbonate (30 mEq/L, normal 22-26
mEq/L) represents renal compensation, where the kidneys retain bicarbonate over days to
weeks to buffer the chronic acid load. This is a chronic, compensated respiratory acidosis. The
nurse must administer controlled, low-flow oxygen (typically 1-2 L/min via nasal cannula)
because COPD patients may rely on hypoxic drive for ventilation. Aggressive oxygen
supplementation can suppress the hypoxic drive and precipitate respiratory failure.
A 58-year-old woman is admitted following a massive pulmonary embolism. She is hypotensive
(BP 82/50 mmHg), tachycardic (HR 128 bpm), and her neck veins are markedly
distended. Her chest X-ray is clear, and her ECG shows a new S1Q3T3 pattern. The
nurse anticipates which hemodynamic change as the primary pathophysiological
mechanism causing her hypotension?
A. Left ventricular failure causing reduced cardiac output B. Acute right ventricular strain causing
reduced pulmonary blood flow and decreased left ventricular preload C. Systemic vasodilation
caused by inflammatory mediator release D. Pericardial tamponade causing compression of all
cardiac chambers
Correct Answer: B
Rationale: A massive pulmonary embolism obstructs pulmonary arterial flow, causing acute right
ventricular pressure overload and strain. The right ventricle dilates and fails, reducing the
amount of blood traversing the pulmonary circulation to reach the left side of the heart. This
dramatically decreases left ventricular preload and consequently stroke volume and cardiac
output, causing obstructive shock. Jugular venous distension reflects the backed-up right-sided
1
, pressure. The S1Q3T3 pattern on ECG (deep S wave in lead I, Q wave and T wave inversion in
lead III) is a classic but non-specific sign of acute right heart strain. Management priorities
include anticoagulation, systemic thrombolytics if hemodynamically unstable, and possibly
catheter-directed therapy or surgical embolectomy.
A 72-year-old woman with a history of hypertension and type 2 diabetes is brought to the ED by
her daughter, who states her mother has been "confused and not acting herself" for the
past 6 hours. On assessment, the patient scores 13 on the Glasgow Coma Scale, is oriented
only to person, has right-sided facial droop, and arm drift. Her blood pressure is 188/102
mmHg. CT scan of the head is negative for hemorrhage. The thrombolytic therapy
window has not been exceeded. The nurse prepares for alteplase (tPA) administration and
is aware that a contraindication to tPA in ischemic stroke includes:
A. Age greater than 65 years B. Blood pressure of 188/102 mmHg before treatment C. Blood glucose
below 50 mg/dL or above 400 mg/dL D. Presence of right-sided deficits only
Correct Answer: C
Rationale: Hypoglycemia (glucose below 50 mg/dL) is a critical contraindication to tPA because it can
mimic ischemic stroke and is immediately reversible; administering tPA unnecessarily carries
serious hemorrhagic risk. Hyperglycemia above 400 mg/dL is also a relative contraindication.
Age alone is not a contraindication to tPA in eligible patients. Blood pressure of 188/102
mmHg must be controlled to below 185/110 mmHg before tPA administration and maintained
below 180/105 mmHg during and after infusion, but is not an absolute contraindication if
controllable. The nurse must ensure blood glucose is checked, BP is managed (typically with IV
labetalol or nicardipine), and informed consent is obtained before administration.
A 55-year-old man with no prior cardiac history is admitted with crushing chest pain radiating
to the left jaw and arm, diaphoresis, and nausea for the past 90 minutes. His 12-lead ECG
shows ST elevation in leads II, III, and aVF. The nurse recognizes this pattern as
indicative of:
A. Anterior STEMI involving the left anterior descending artery B. Lateral STEMI involving the left
circumflex artery C. Inferior STEMI involving the right coronary artery D. Posterior STEMI
requiring additional leads to confirm
Correct Answer: C
Rationale: ST elevation in the inferior leads (II, III, and aVF) classically represents an inferior wall
STEMI, most commonly caused by occlusion of the right coronary artery (RCA), which supplies
the inferior wall of the left ventricle, the right ventricle, and the SA and AV nodes in most
patients. This distinction is clinically critical because inferior STEMIs are frequently
associated with right ventricular infarction (present in up to 40% of cases), requiring the nurse
to obtain right-sided leads (V4R), avoid nitrates (which reduce preload and can cause severe
hypotension in RV infarction), and administer IV fluid challenges instead. The nurse must
activate the cardiac catheterization lab immediately, targeting door-to-balloon time within 90
minutes.
A 48-year-old woman undergoes a total thyroidectomy for thyroid cancer. Six hours
postoperatively, she reports tingling and numbness around her mouth and in her
fingertips. The nurse assesses for Chvostek's sign by tapping the facial nerve and observes
twitching of the facial muscles. The nurse's priority action is to:
A. Reassure the patient that this is expected postoperative anxiety B. Assess serum calcium
immediately and prepare for IV calcium gluconate administration C. Administer oral calcium
carbonate tablets and observe for 24 hours D. Check serum potassium, as hypokalemia causes
identical symptoms
2
, Correct Answer: B
Rationale: Total thyroidectomy carries the risk of inadvertent removal or devascularization of all four
parathyroid glands, which lie in close proximity to the thyroid. Loss of parathyroid function
causes acute hypoparathyroidism, resulting in hypocalcemia, which typically manifests within
24-48 hours postoperatively. Circumoral numbness, fingertip tingling, positive Chvostek's sign
(facial nerve twitching), and Trousseau's sign (carpal spasm with BP cuff inflation) are
hallmarks of hypocalcemic tetany. Untreated hypocalcemia progresses to laryngospasm,
bronchospasm, seizures, and fatal cardiac arrhythmias. IV calcium gluconate is the immediate
treatment for symptomatic hypocalcemia, followed by ongoing monitoring, oral calcium, and
vitamin D supplementation.
A 63-year-old man with known cirrhosis of the liver presents with acute confusion, asterixis
(flapping tremor), and increasing abdominal girth. His ammonia level is 148 mcmol/L
(normal less than 35 mcmol/L). The physician orders lactulose 30 mL orally three times
daily. The nurse correctly explains the mechanism of lactulose to the student nurse as:
A. Lactulose directly binds ammonia in the bloodstream, removing it from circulation B. Lactulose
acidifies colonic contents, trapping ammonia as ammonium ion and promoting its excretion in
stool while also functioning as an osmotic laxative C. Lactulose stimulates the liver to
metabolize ammonia through the urea cycle D. Lactulose reduces ammonia production by
killing ammonia-producing gut bacteria directly
Correct Answer: B
Rationale: Lactulose is a synthetic, non-absorbable disaccharide metabolized by colonic bacteria into
organic acids (primarily lactic and acetic acid). This acidifies the colonic lumen, lowering pH
to approximately 5-6. At this acidic pH, ammonia (NH3), which freely crosses cell membranes,
is converted to the ammonium ion (NH4+), which is ionized and cannot be absorbed back into
the portal circulation. Additionally, the osmotic effect of lactulose causes diarrhea, physically
expelling ammonium-laden stool. The target is 2-4 soft stools per day. Rifaximin, a non-
absorbable antibiotic, is often added to reduce ammonia-producing bacteria. The nurse must
monitor for excessive diarrhea causing electrolyte imbalances and dehydration.
A 76-year-old woman is brought to the ED following a fall. She is alert and oriented but reports
severe left hip pain and inability to bear weight. On assessment, the nurse observes that
her left leg is shortened, externally rotated, and adducted. X-ray confirms a displaced
femoral neck fracture. The nurse recognizes that this patient's highest postoperative
priority concern, beyond pain management, is prevention of:
A. Wound dehiscence and surgical site infection B. Venous thromboembolism and fat embolism
syndrome C. Postoperative pneumonia only D. Urinary tract infection from prolonged
catheterization
Correct Answer: B
Rationale: Hip fractures and subsequent surgical repair (hemiarthroplasty or total hip arthroplasty)
carry extremely high risks of venous thromboembolism (DVT and pulmonary embolism), which
is among the leading causes of postoperative mortality in this population. Fat embolism
syndrome (FES) can occur when fatty marrow enters the venous circulation during fracture
manipulation or reaming, causing the classic triad of hypoxemia, neurological changes, and
petechial rash, typically within 24-72 hours postoperatively. VTE prophylaxis (LMWH,
fondaparinux, or rivaroxaban), early mobilization, compression stockings, and pneumatic
sequential compression devices are essential. All other complications listed are important but
carry comparatively lower mortality risk in this specific scenario.
A 34-year-old woman at 32 weeks gestation is admitted with blood pressure of 156/104 mmHg on
3
