NUR185/NUR 185 Final Exam V2 |
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 who is 24 hours post-operative following a total hip
arthroplasty. Which of the following actions is most important for the nurse to take to
prevent dislocation?
A. Maintain the patient’s legs in an adducted position.
B. Keep an abductor pillow between the patient’s legs.
C. Encourage the patient to cross their legs while sitting.
D. Flex the hip more than 90 degrees when sitting.
Correct Answer: B
Rationale: Using an abductor pillow prevents the surgical hip from crossing the midline,
which is essential to prevent dislocation. The nurse must ensure the patient avoids
adduction and extreme hip flexion during the early recovery phase. Proper positioning is a
priority nursing intervention for musculoskeletal integrity after joint replacement.
,2. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is typically recommended for this patient population to
prevent respiratory depression?
A. 1 to 2 L/min
B. 5 to 6 L/min
C. 8 to 10 L/min
D. 12 to 15 L/min
Correct Answer: A
Rationale: Patients with COPD often rely on a hypoxic drive to breathe rather than high
carbon dioxide levels. Administering high concentrations of oxygen can suppress this drive,
leading to respiratory arrest. Therefore, low-flow oxygen, usually 1 to 2 L/min, is the
standard of care for maintaining safe saturation levels.
3. The nurse is monitoring a patient who just returned from a cardiac catheterization. Which
of the following is the priority nursing assessment?
A. Check the temperature of the extremities.
B. Evaluate the patient’s level of pain.
C. Assess the puncture site for bleeding and hematoma.
D. Monitor the patient’s urinary output.
Correct Answer: C
, Rationale: Post-cardiac catheterization, the most significant risk is hemorrhage at the
femoral or radial artery insertion site. The nurse must frequently monitor the site for
hematoma formation or active bleeding to ensure hemodynamic stability. Additionally,
distal pulses should be checked to verify adequate circulation to the affected limb.
4. A nurse is preparing to administer digoxin to a patient with heart failure. Which action
should the nurse take before giving the medication?
A. Assess the blood pressure in both arms.
B. Auscultate the apical pulse for one full minute.
C. Check the radial pulse for 30 seconds.
D. Review the patient’s latest serum sodium level.
Correct Answer: B
Rationale: Digoxin decreases the heart rate while increasing contractility, so the apical
pulse must be monitored to ensure it is at least 60 beats per minute. If the heart rate is
below this threshold, the medication should be withheld and the provider notified. This
safety check prevents the exacerbation of bradycardia in cardiac patients.
5. A patient is diagnosed with left-sided heart failure. Which clinical manifestation should the
nurse expect to find during the assessment?
A. Dependent edema in the ankles.
B. Crackles upon auscultation of the lungs.
C. Jugular vein distention (JVD).
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 who is 24 hours post-operative following a total hip
arthroplasty. Which of the following actions is most important for the nurse to take to
prevent dislocation?
A. Maintain the patient’s legs in an adducted position.
B. Keep an abductor pillow between the patient’s legs.
C. Encourage the patient to cross their legs while sitting.
D. Flex the hip more than 90 degrees when sitting.
Correct Answer: B
Rationale: Using an abductor pillow prevents the surgical hip from crossing the midline,
which is essential to prevent dislocation. The nurse must ensure the patient avoids
adduction and extreme hip flexion during the early recovery phase. Proper positioning is a
priority nursing intervention for musculoskeletal integrity after joint replacement.
,2. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is typically recommended for this patient population to
prevent respiratory depression?
A. 1 to 2 L/min
B. 5 to 6 L/min
C. 8 to 10 L/min
D. 12 to 15 L/min
Correct Answer: A
Rationale: Patients with COPD often rely on a hypoxic drive to breathe rather than high
carbon dioxide levels. Administering high concentrations of oxygen can suppress this drive,
leading to respiratory arrest. Therefore, low-flow oxygen, usually 1 to 2 L/min, is the
standard of care for maintaining safe saturation levels.
3. The nurse is monitoring a patient who just returned from a cardiac catheterization. Which
of the following is the priority nursing assessment?
A. Check the temperature of the extremities.
B. Evaluate the patient’s level of pain.
C. Assess the puncture site for bleeding and hematoma.
D. Monitor the patient’s urinary output.
Correct Answer: C
, Rationale: Post-cardiac catheterization, the most significant risk is hemorrhage at the
femoral or radial artery insertion site. The nurse must frequently monitor the site for
hematoma formation or active bleeding to ensure hemodynamic stability. Additionally,
distal pulses should be checked to verify adequate circulation to the affected limb.
4. A nurse is preparing to administer digoxin to a patient with heart failure. Which action
should the nurse take before giving the medication?
A. Assess the blood pressure in both arms.
B. Auscultate the apical pulse for one full minute.
C. Check the radial pulse for 30 seconds.
D. Review the patient’s latest serum sodium level.
Correct Answer: B
Rationale: Digoxin decreases the heart rate while increasing contractility, so the apical
pulse must be monitored to ensure it is at least 60 beats per minute. If the heart rate is
below this threshold, the medication should be withheld and the provider notified. This
safety check prevents the exacerbation of bradycardia in cardiac patients.
5. A patient is diagnosed with left-sided heart failure. Which clinical manifestation should the
nurse expect to find during the assessment?
A. Dependent edema in the ankles.
B. Crackles upon auscultation of the lungs.
C. Jugular vein distention (JVD).
