LATEST NURS 3365 EXAM 2 - NURSING
EXAM | COMPLETE EXAM WITH CORRECT
ANSWERS AND RATIONALES. A+
GUARANTEED SUCCESS
1. A nurse is preparing to administer a blood
transfusion to a client. Which intravenous solution is
compatible with blood products?
A) 5% dextrose in water
B) 0.9% normal saline
C) Lactated Ringer solution
D) 0.45% normal saline
Correct answer: B
Rationale: Only 0.9% normal saline is compatible with
blood products. Dextrose solutions can cause
hemolysis. Lactated Ringer contains calcium, which
can activate the clotting cascade. Hypotonic
solutions cause red blood cell lysis.
2. A nurse is caring for a client who is receiving a
continuous heparin infusion for deep vein
thrombosis. Which laboratory value indicates the
heparin is therapeutic?
,A) aPTT of 45 seconds (normal control 30 seconds)
B) aPTT of 75 seconds (normal control 30 seconds)
C) INR of 2.5
D) INR of 3.5
Correct answer: B
Rationale: The therapeutic aPTT range for heparin is
1.5 to 2.5 times the normal control. 30 x 1.5 = 45; 30 x
2.5 = 75. 75 is at the upper limit of therapeutic. INR is
used to monitor warfarin.
3. A nurse is providing discharge teaching to a client
with a new diagnosis of heart failure. Which
statement by the client indicates a need for further
teaching?
A) I will weigh myself every morning before breakfast
B) I will call my provider if I gain 2 pounds in one day
C) I can add salt to my food at the table as long as I do
not cook with salt
D) I will take my diuretic in the morning so I do not
wake up at night
Correct answer: C
Rationale: Clients with heart failure should follow a
low-sodium diet, which includes avoiding adding salt
at the table. Daily weights, calling for a 2-3 pound
,gain in a day, and taking diuretics in the morning are
correct.
4. A nurse is caring for a client who is postoperative
and has a patient-controlled analgesia (PCA) pump.
The client is somnolent and has a respiratory rate of 8
breaths per minute. What is the priority action?
A) Instruct the client to take deep breaths
B) Stop the PCA infusion and notify the provider
C) Increase the PCA lockout interval
D) Apply oxygen at 2 L per minute via nasal cannula
Correct answer: B
Rationale: A respiratory rate of 8 with somnolence
indicates opioid-induced respiratory depression. The
PCA infusion should be stopped immediately, and the
provider should be notified. Oxygen and stimulation
are supportive but do not address the cause.
5. A nurse is assessing a client who is 2 hours
postoperative after abdominal surgery. Which finding
requires immediate intervention?
A) The client reports pain of 6 on a 0-to-10 scale
B) The client's heart rate is 110 beats per minute and
blood pressure is 90/50 mm Hg
, C) The client's oxygen saturation is 94% on room air
D) The client has not yet voided
Correct answer: B
Rationale: Tachycardia with hypotension in the
postoperative period may indicate hypovolemia from
hemorrhage or dehydration and requires immediate
assessment. Pain is expected. Oxygen saturation of
94% is acceptable. Not voiding at 2 hours is not yet
concerning.
6. A nurse is preparing to administer an
intramuscular injection of vitamin K to a newborn.
Which site is most appropriate?
A) Ventrogluteal
B) Dorsogluteal
C) Vastus lateralis
D) Deltoid
Correct answer: C
Rationale: The vastus lateralis is the preferred site
for intramuscular injections in newborns and infants
because it is well developed and free of major nerves
and blood vessels.
EXAM | COMPLETE EXAM WITH CORRECT
ANSWERS AND RATIONALES. A+
GUARANTEED SUCCESS
1. A nurse is preparing to administer a blood
transfusion to a client. Which intravenous solution is
compatible with blood products?
A) 5% dextrose in water
B) 0.9% normal saline
C) Lactated Ringer solution
D) 0.45% normal saline
Correct answer: B
Rationale: Only 0.9% normal saline is compatible with
blood products. Dextrose solutions can cause
hemolysis. Lactated Ringer contains calcium, which
can activate the clotting cascade. Hypotonic
solutions cause red blood cell lysis.
2. A nurse is caring for a client who is receiving a
continuous heparin infusion for deep vein
thrombosis. Which laboratory value indicates the
heparin is therapeutic?
,A) aPTT of 45 seconds (normal control 30 seconds)
B) aPTT of 75 seconds (normal control 30 seconds)
C) INR of 2.5
D) INR of 3.5
Correct answer: B
Rationale: The therapeutic aPTT range for heparin is
1.5 to 2.5 times the normal control. 30 x 1.5 = 45; 30 x
2.5 = 75. 75 is at the upper limit of therapeutic. INR is
used to monitor warfarin.
3. A nurse is providing discharge teaching to a client
with a new diagnosis of heart failure. Which
statement by the client indicates a need for further
teaching?
A) I will weigh myself every morning before breakfast
B) I will call my provider if I gain 2 pounds in one day
C) I can add salt to my food at the table as long as I do
not cook with salt
D) I will take my diuretic in the morning so I do not
wake up at night
Correct answer: C
Rationale: Clients with heart failure should follow a
low-sodium diet, which includes avoiding adding salt
at the table. Daily weights, calling for a 2-3 pound
,gain in a day, and taking diuretics in the morning are
correct.
4. A nurse is caring for a client who is postoperative
and has a patient-controlled analgesia (PCA) pump.
The client is somnolent and has a respiratory rate of 8
breaths per minute. What is the priority action?
A) Instruct the client to take deep breaths
B) Stop the PCA infusion and notify the provider
C) Increase the PCA lockout interval
D) Apply oxygen at 2 L per minute via nasal cannula
Correct answer: B
Rationale: A respiratory rate of 8 with somnolence
indicates opioid-induced respiratory depression. The
PCA infusion should be stopped immediately, and the
provider should be notified. Oxygen and stimulation
are supportive but do not address the cause.
5. A nurse is assessing a client who is 2 hours
postoperative after abdominal surgery. Which finding
requires immediate intervention?
A) The client reports pain of 6 on a 0-to-10 scale
B) The client's heart rate is 110 beats per minute and
blood pressure is 90/50 mm Hg
, C) The client's oxygen saturation is 94% on room air
D) The client has not yet voided
Correct answer: B
Rationale: Tachycardia with hypotension in the
postoperative period may indicate hypovolemia from
hemorrhage or dehydration and requires immediate
assessment. Pain is expected. Oxygen saturation of
94% is acceptable. Not voiding at 2 hours is not yet
concerning.
6. A nurse is preparing to administer an
intramuscular injection of vitamin K to a newborn.
Which site is most appropriate?
A) Ventrogluteal
B) Dorsogluteal
C) Vastus lateralis
D) Deltoid
Correct answer: C
Rationale: The vastus lateralis is the preferred site
for intramuscular injections in newborns and infants
because it is well developed and free of major nerves
and blood vessels.
