NUR185/NUR 185 Exam 3 V3 | Concepts of
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a patient diagnosed with Chronic Kidney Disease (CKD) who is
receiving hemodialysis. Which assessment finding should the nurse prioritize as a
complication of the treatment?
A. Weight gain of 1 lb since last treatment
B. Blood pressure of 142/88 mmHg
C. Potassium level of 4.2 mEq/L
D. Muscle cramps and headache
Correct Answer: D
Rationale: Muscle cramps and headaches are common signs of disequilibrium syndrome
or rapid fluid shifts during hemodialysis. The nurse must monitor these symptoms closely
as they can lead to cerebral edema or seizures. Maintaining a safe rate of fluid removal is
essential to prevent these neurological complications.
2. When assessing a patient with a newly created Arteriovenous (AV) fistula, which finding
indicates the access is patent?
A. Presence of a radial pulse distal to the site
,B. Painless range of motion in the wrist
C. Absence of edema in the affected extremity
D. A palpable thrill and audible bruit over the site
Correct Answer: D
Rationale: A palpable thrill and an audible bruit are the definitive signs that blood is
flowing properly through the AV fistula. The thrill is a vibration felt upon palpation, while
the bruit is a swishing sound heard with a stethoscope. Nurses must assess for these signs
every shift to ensure the access remains viable for dialysis.
3. A patient with heart failure is prescribed Furosemide. Which laboratory value should the
nurse monitor most closely to prevent toxicity or complications?
A. Serum Sodium
B. Blood Urea Nitrogen
C. Serum Creatinine
D. Serum Potassium
Correct Answer: D
Rationale: Furosemide is a loop diuretic that causes the excretion of potassium along with
water and sodium. Low potassium levels, or hypokalemia, can predispose the patient to
dangerous cardiac arrhythmias and increase the risk of Digoxin toxicity. The nurse should
encourage potassium-rich foods or administer supplements as prescribed by the provider.
, 4. The nurse is reviewing the discharge plan for a patient with Congestive Heart Failure (CHF).
Which instruction is most critical for the patient to follow daily?
A. Limit physical activity to bed rest
B. Increase fluid intake to 3 liters per day
C. Weigh yourself at the same time every morning
D. Take an extra dose of diuretics if ankles swell
Correct Answer: C
Rationale: Daily weights are the most sensitive indicator of fluid volume status in patients
with heart failure. A weight gain of more than 2-3 pounds in a day or 5 pounds in a week
must be reported to the healthcare provider immediately. This allows for early
intervention before the patient develops acute pulmonary edema.
5. A patient is admitted with an exacerbation of COPD. The nurse notes the patient is using
pursed-lip breathing. What is the primary purpose of this breathing technique?
A. To prevent airway collapse during expiration
B. To strengthen the diaphragm muscle
C. To increase the respiratory rate
D. To decrease the amount of oxygen reaching the lungs
Correct Answer: A
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a patient diagnosed with Chronic Kidney Disease (CKD) who is
receiving hemodialysis. Which assessment finding should the nurse prioritize as a
complication of the treatment?
A. Weight gain of 1 lb since last treatment
B. Blood pressure of 142/88 mmHg
C. Potassium level of 4.2 mEq/L
D. Muscle cramps and headache
Correct Answer: D
Rationale: Muscle cramps and headaches are common signs of disequilibrium syndrome
or rapid fluid shifts during hemodialysis. The nurse must monitor these symptoms closely
as they can lead to cerebral edema or seizures. Maintaining a safe rate of fluid removal is
essential to prevent these neurological complications.
2. When assessing a patient with a newly created Arteriovenous (AV) fistula, which finding
indicates the access is patent?
A. Presence of a radial pulse distal to the site
,B. Painless range of motion in the wrist
C. Absence of edema in the affected extremity
D. A palpable thrill and audible bruit over the site
Correct Answer: D
Rationale: A palpable thrill and an audible bruit are the definitive signs that blood is
flowing properly through the AV fistula. The thrill is a vibration felt upon palpation, while
the bruit is a swishing sound heard with a stethoscope. Nurses must assess for these signs
every shift to ensure the access remains viable for dialysis.
3. A patient with heart failure is prescribed Furosemide. Which laboratory value should the
nurse monitor most closely to prevent toxicity or complications?
A. Serum Sodium
B. Blood Urea Nitrogen
C. Serum Creatinine
D. Serum Potassium
Correct Answer: D
Rationale: Furosemide is a loop diuretic that causes the excretion of potassium along with
water and sodium. Low potassium levels, or hypokalemia, can predispose the patient to
dangerous cardiac arrhythmias and increase the risk of Digoxin toxicity. The nurse should
encourage potassium-rich foods or administer supplements as prescribed by the provider.
, 4. The nurse is reviewing the discharge plan for a patient with Congestive Heart Failure (CHF).
Which instruction is most critical for the patient to follow daily?
A. Limit physical activity to bed rest
B. Increase fluid intake to 3 liters per day
C. Weigh yourself at the same time every morning
D. Take an extra dose of diuretics if ankles swell
Correct Answer: C
Rationale: Daily weights are the most sensitive indicator of fluid volume status in patients
with heart failure. A weight gain of more than 2-3 pounds in a day or 5 pounds in a week
must be reported to the healthcare provider immediately. This allows for early
intervention before the patient develops acute pulmonary edema.
5. A patient is admitted with an exacerbation of COPD. The nurse notes the patient is using
pursed-lip breathing. What is the primary purpose of this breathing technique?
A. To prevent airway collapse during expiration
B. To strengthen the diaphragm muscle
C. To increase the respiratory rate
D. To decrease the amount of oxygen reaching the lungs
Correct Answer: A
