NUR 2356 MDC part 3
1 Final Exam Practice Test:
High-Yield 250-Question Practice Exam (Questions 51–100) with Integrated
Answers and Expert Clinical Rationales Covering Advanced DVT Prevention,
Isolation Safety, and High-Alert Medication Safety.
1. A client is admitted with severe muscle weakness, hyporeflexia, and an
electrocardiogram (ECG) demonstrating flattened T waves and prominent U waves.
Which electrolyte imbalance is present?
A) Hyperkalemia
B) Hyponatremia
C) Hypokalemia
D) Hypercalcemia
Answer: C) Hypokalemia
.
2. A client's arterial blood gas (ABG) results show: pH 7.28, PaCO₂ 54 mmHg, and HCO₃⁻
25 mEq/L. How should the nurse interpret these findings?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: C) Respiratory acidosis
Rationale: A pH below 7.35 indicates acidosis. The PaCO₂ is elevated above 45 mmHg,
demonstrating that the respiratory system is retaining carbon dioxide (an acid). Because
the bicarbonate level (HCO₃⁻) is within the normal reference range of 22–26 mEq/L, this
is an uncompensated respiratory acidosis.
3. A nurse is planning care for a client who is scheduled for an elective surgery. Which of
the following details represents the nurse's legal responsibility regarding informed
consent?
A) Explaining the specific risks and benefits of the surgery
, B) Outlining alternative non-surgical treatment options
C) Witnessing the client's signature on the consent form
D) Describing the technical steps of the surgical procedure
Answer: C) Witnessing the client's signature on the consent form
Rationale: The nurse's role in informed consent is limited to witnessing the signature.
This confirms that the client is competent, signs voluntarily, and understands that they
are signing a consent document. Explaining risks, benefits, alternatives, and procedures
remains the sole legal responsibility of the surgeon.
4. During a surgical procedure under general anesthesia, the circulating nurse notes that
the client develops generalized muscle rigidity, a heart rate of 135 beats/minute, and a
rapidly rising body temperature of 103°F (39.4°C). Which medication should the nurse
anticipate administering?
A) Succinylcholine
B) Dantrolene sodium
C) Furosemide
D) Propofol
Answer: B) Dantrolene sodium
Rationale: Muscle rigidity, hypercapnia, tachycardia, and a hypermetabolic spike in
temperature are classic signs of malignant hyperthermia. This is a life-threatening
genetic reaction to volatile inhalation anesthetics. Dantrolene sodium is the specific
antidote that halts abnormal calcium release from the sarcoplasmic reticulum.
5. A nurse is assessing an area of intact skin over a bedbound client's sacrum. The skin
exhibits a localized area of non-blanchable erythema. How should the nurse stage this
pressure injury?
A) Stage 1
B) Stage 2
C) Stage 3
D) Deep tissue pressure injury
Answer: A) Stage 1
Rationale: A stage 1 pressure injury is defined by intact skin featuring localized, non-
blanchable redness. If the skin remains red and does not turn white when light pressure
is applied, it indicates localized tissue ischemia.
6. A client with a large abdominal incision coughs violently and states, "I felt my stomach
rip open." The nurse notes that the incision edges have separated entirely and a loop of
the small intestine is visible. Which action should the nurse take first?
A) Manually push the protruding loop of bowel back into the abdominal cavity
B) Cover the open wound with sterile dressings moistened with warm sterile normal
saline
C) Apply a tight, compressive abdominal binder over the wound site
D) Assist the client into a high-Fowler's position to assist breathing
Answer: B) Cover the open wound with sterile dressings moistened with warm
sterile normal saline
Rationale: This situation describes a wound evisceration, which is a critical medical
emergency. The nurse's immediate priority is to protect the exposed viscera from drying
out and developing ischemia by covering them with sterile dressings saturated with
warm sterile normal saline.
,7. A nurse is caring for an immobile client. Which intervention is the most effective
evidence-based method for preventing pressure injury development?
A) Massaging any reddened bony prominences daily
B) Repositioning the client in bed at least every 2 hours
C) Keeping the head of the bed continuously elevated at 45 degrees
D) Placing a donut-shaped cushion under the client's hips
Answer: B) Repositioning the client in bed at least every 2 hours
Rationale: Turning the client at least every 2 hours relieves localized pressure on
vulnerable bony areas, restoring blood flow to ischemic tissues. Massaging red areas,
using donut cushions, and prolonged high head elevation cause friction, shearing, and
localized tissue damage.
8. A client is admitted with severe, unremitting diarrhea for 3 days. Which acid-base
imbalance should the nurse monitor this client for?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: A) Metabolic acidosis
Rationale: Lower gastrointestinal secretions are highly alkaline and rich in sodium
bicarbonate. Severe diarrhea results in a massive loss of base (bicarbonate) from the
body, which lowers the systemic pH and leads to metabolic acidosis.
9. A nurse is assessing a client who has a serum sodium level of 156 mEq/L. Which
clinical finding should the nurse expect?
A) Hyperactive bowel sounds
B) Decreased deep tendon reflexes
C) Intense thirst and dry, sticky mucous membranes
D) Postural hypotension
Answer: C) Intense thirst and dry, sticky mucous membranes
Rationale: A sodium level above 145 mEq/L indicates hypernatremia. This hypertonic
state pulls water out of body cells into the intravascular space, causing intracellular
dehydration. This manifests as intense thirst, dry sticky mucous membranes,
restlessness, and confusion.
10. A nurse is caring for a client in the post-anesthesia care unit (PACU) following general
anesthesia. The client has a respiratory rate of 8 breaths/minute and an oxygen
saturation of 87%. Which action should the nurse take first?
A) Prepare to administer intravenous naloxone
B) Stimulate the client physically and verbally prompt them to deep-breathe
C) Apply oxygen via a high-flow non-rebreather mask
D) Call the attending surgeon to report the findings
Answer: B) Stimulate the client physically and verbally prompt them to deep-
breathe
Rationale: Postoperative hypoventilation is commonly due to residual sedation or
anesthesia. The first and least invasive action is to physically stimulate the client (such
as shaking the shoulder) and verbally cue them to take deep breaths before progressing
to invasive or pharmacological interventions.
, 11. A nurse is reviewing morning lab values for a client scheduled for surgery. Which result
must be reported to the surgeon immediately?
A) Hemoglobin 14 g/dL
B) Potassium 2.8 mEq/L
C) Sodium 138 mEq/L
D) White blood cell count 8,200/mm³
Answer: B) Potassium 2.8 mEq/L
Rationale: A potassium level below 3.5 mEq/L indicates hypokalemia. Severe
hypokalemia can trigger fatal cardiac arrhythmias during anesthesia and surgical
manipulation, making it a critical finding that must be corrected preoperatively.
12. A nurse is assessing a wound that has thick, opaque, yellow-green drainage with a foul
odor. How should the nurse document this type of exudate?
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulent
Answer: D) Purulent
Rationale: Purulent drainage is thick and varies from milky white to yellow or green. It
consists of live and dead bacteria, white blood cells, and liquefied necrotic cellular
debris, which confirms a localized wound infection.
13. A client has an order for a continuous IV infusion of 3% sodium chloride. The nurse
understands that this fluid belongs to which classification?
A) Hypotonic crystalloid
B) Isotonic crystalloid
C) Hypertonic crystalloid
D) Colloid solution
Answer: C) Hypertonic crystalloid
Rationale: A 3% sodium chloride solution has an osmolality significantly higher than that
of plasma. When infused, it pulls fluid out of the intracellular space and into the
intravascular compartment, making it a hypertonic crystalloid solution.
14. A client's arterial blood gas results are: pH 7.48, PaCO₂ 40 mmHg, and HCO₃⁻ 31
mEq/L. How should the nurse interpret these findings?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: B) Metabolic alkalosis
Rationale: A pH greater than 7.45 indicates alkalosis. Because the PaCO₂ is normal
(35–45 mmHg) and the bicarbonate level (HCO₃⁻) is elevated above 26 mEq/L, the
origin of the alkalosis is metabolic.
15. Which of the following clients is at the highest risk for developing respiratory acidosis?
A) A client with an acute anxiety attack who is hyperventilating
B) A client with chronic obstructive pulmonary disease (COPD)
C) A client with severe diarrhea for 48 hours
D) A client using excessive antacids containing sodium bicarbonate
Answer: B) A client with chronic obstructive pulmonary disease (COPD)
1 Final Exam Practice Test:
High-Yield 250-Question Practice Exam (Questions 51–100) with Integrated
Answers and Expert Clinical Rationales Covering Advanced DVT Prevention,
Isolation Safety, and High-Alert Medication Safety.
1. A client is admitted with severe muscle weakness, hyporeflexia, and an
electrocardiogram (ECG) demonstrating flattened T waves and prominent U waves.
Which electrolyte imbalance is present?
A) Hyperkalemia
B) Hyponatremia
C) Hypokalemia
D) Hypercalcemia
Answer: C) Hypokalemia
.
2. A client's arterial blood gas (ABG) results show: pH 7.28, PaCO₂ 54 mmHg, and HCO₃⁻
25 mEq/L. How should the nurse interpret these findings?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: C) Respiratory acidosis
Rationale: A pH below 7.35 indicates acidosis. The PaCO₂ is elevated above 45 mmHg,
demonstrating that the respiratory system is retaining carbon dioxide (an acid). Because
the bicarbonate level (HCO₃⁻) is within the normal reference range of 22–26 mEq/L, this
is an uncompensated respiratory acidosis.
3. A nurse is planning care for a client who is scheduled for an elective surgery. Which of
the following details represents the nurse's legal responsibility regarding informed
consent?
A) Explaining the specific risks and benefits of the surgery
, B) Outlining alternative non-surgical treatment options
C) Witnessing the client's signature on the consent form
D) Describing the technical steps of the surgical procedure
Answer: C) Witnessing the client's signature on the consent form
Rationale: The nurse's role in informed consent is limited to witnessing the signature.
This confirms that the client is competent, signs voluntarily, and understands that they
are signing a consent document. Explaining risks, benefits, alternatives, and procedures
remains the sole legal responsibility of the surgeon.
4. During a surgical procedure under general anesthesia, the circulating nurse notes that
the client develops generalized muscle rigidity, a heart rate of 135 beats/minute, and a
rapidly rising body temperature of 103°F (39.4°C). Which medication should the nurse
anticipate administering?
A) Succinylcholine
B) Dantrolene sodium
C) Furosemide
D) Propofol
Answer: B) Dantrolene sodium
Rationale: Muscle rigidity, hypercapnia, tachycardia, and a hypermetabolic spike in
temperature are classic signs of malignant hyperthermia. This is a life-threatening
genetic reaction to volatile inhalation anesthetics. Dantrolene sodium is the specific
antidote that halts abnormal calcium release from the sarcoplasmic reticulum.
5. A nurse is assessing an area of intact skin over a bedbound client's sacrum. The skin
exhibits a localized area of non-blanchable erythema. How should the nurse stage this
pressure injury?
A) Stage 1
B) Stage 2
C) Stage 3
D) Deep tissue pressure injury
Answer: A) Stage 1
Rationale: A stage 1 pressure injury is defined by intact skin featuring localized, non-
blanchable redness. If the skin remains red and does not turn white when light pressure
is applied, it indicates localized tissue ischemia.
6. A client with a large abdominal incision coughs violently and states, "I felt my stomach
rip open." The nurse notes that the incision edges have separated entirely and a loop of
the small intestine is visible. Which action should the nurse take first?
A) Manually push the protruding loop of bowel back into the abdominal cavity
B) Cover the open wound with sterile dressings moistened with warm sterile normal
saline
C) Apply a tight, compressive abdominal binder over the wound site
D) Assist the client into a high-Fowler's position to assist breathing
Answer: B) Cover the open wound with sterile dressings moistened with warm
sterile normal saline
Rationale: This situation describes a wound evisceration, which is a critical medical
emergency. The nurse's immediate priority is to protect the exposed viscera from drying
out and developing ischemia by covering them with sterile dressings saturated with
warm sterile normal saline.
,7. A nurse is caring for an immobile client. Which intervention is the most effective
evidence-based method for preventing pressure injury development?
A) Massaging any reddened bony prominences daily
B) Repositioning the client in bed at least every 2 hours
C) Keeping the head of the bed continuously elevated at 45 degrees
D) Placing a donut-shaped cushion under the client's hips
Answer: B) Repositioning the client in bed at least every 2 hours
Rationale: Turning the client at least every 2 hours relieves localized pressure on
vulnerable bony areas, restoring blood flow to ischemic tissues. Massaging red areas,
using donut cushions, and prolonged high head elevation cause friction, shearing, and
localized tissue damage.
8. A client is admitted with severe, unremitting diarrhea for 3 days. Which acid-base
imbalance should the nurse monitor this client for?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: A) Metabolic acidosis
Rationale: Lower gastrointestinal secretions are highly alkaline and rich in sodium
bicarbonate. Severe diarrhea results in a massive loss of base (bicarbonate) from the
body, which lowers the systemic pH and leads to metabolic acidosis.
9. A nurse is assessing a client who has a serum sodium level of 156 mEq/L. Which
clinical finding should the nurse expect?
A) Hyperactive bowel sounds
B) Decreased deep tendon reflexes
C) Intense thirst and dry, sticky mucous membranes
D) Postural hypotension
Answer: C) Intense thirst and dry, sticky mucous membranes
Rationale: A sodium level above 145 mEq/L indicates hypernatremia. This hypertonic
state pulls water out of body cells into the intravascular space, causing intracellular
dehydration. This manifests as intense thirst, dry sticky mucous membranes,
restlessness, and confusion.
10. A nurse is caring for a client in the post-anesthesia care unit (PACU) following general
anesthesia. The client has a respiratory rate of 8 breaths/minute and an oxygen
saturation of 87%. Which action should the nurse take first?
A) Prepare to administer intravenous naloxone
B) Stimulate the client physically and verbally prompt them to deep-breathe
C) Apply oxygen via a high-flow non-rebreather mask
D) Call the attending surgeon to report the findings
Answer: B) Stimulate the client physically and verbally prompt them to deep-
breathe
Rationale: Postoperative hypoventilation is commonly due to residual sedation or
anesthesia. The first and least invasive action is to physically stimulate the client (such
as shaking the shoulder) and verbally cue them to take deep breaths before progressing
to invasive or pharmacological interventions.
, 11. A nurse is reviewing morning lab values for a client scheduled for surgery. Which result
must be reported to the surgeon immediately?
A) Hemoglobin 14 g/dL
B) Potassium 2.8 mEq/L
C) Sodium 138 mEq/L
D) White blood cell count 8,200/mm³
Answer: B) Potassium 2.8 mEq/L
Rationale: A potassium level below 3.5 mEq/L indicates hypokalemia. Severe
hypokalemia can trigger fatal cardiac arrhythmias during anesthesia and surgical
manipulation, making it a critical finding that must be corrected preoperatively.
12. A nurse is assessing a wound that has thick, opaque, yellow-green drainage with a foul
odor. How should the nurse document this type of exudate?
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulent
Answer: D) Purulent
Rationale: Purulent drainage is thick and varies from milky white to yellow or green. It
consists of live and dead bacteria, white blood cells, and liquefied necrotic cellular
debris, which confirms a localized wound infection.
13. A client has an order for a continuous IV infusion of 3% sodium chloride. The nurse
understands that this fluid belongs to which classification?
A) Hypotonic crystalloid
B) Isotonic crystalloid
C) Hypertonic crystalloid
D) Colloid solution
Answer: C) Hypertonic crystalloid
Rationale: A 3% sodium chloride solution has an osmolality significantly higher than that
of plasma. When infused, it pulls fluid out of the intracellular space and into the
intravascular compartment, making it a hypertonic crystalloid solution.
14. A client's arterial blood gas results are: pH 7.48, PaCO₂ 40 mmHg, and HCO₃⁻ 31
mEq/L. How should the nurse interpret these findings?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: B) Metabolic alkalosis
Rationale: A pH greater than 7.45 indicates alkalosis. Because the PaCO₂ is normal
(35–45 mmHg) and the bicarbonate level (HCO₃⁻) is elevated above 26 mEq/L, the
origin of the alkalosis is metabolic.
15. Which of the following clients is at the highest risk for developing respiratory acidosis?
A) A client with an acute anxiety attack who is hyperventilating
B) A client with chronic obstructive pulmonary disease (COPD)
C) A client with severe diarrhea for 48 hours
D) A client using excessive antacids containing sodium bicarbonate
Answer: B) A client with chronic obstructive pulmonary disease (COPD)
