NUR185/NUR 185 Exam 1 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 with a potassium level of 2.9 mEq/L. Which of the following
clinical manifestations should the nurse expect to assess?
A. Hyperactive deep tendon reflexes
B. Muscle weakness and leg cramps
C. Peaked T waves on the ECG
D. Diarrhea and abdominal cramping
Correct Answer: B
Rationale: Hypokalemia often presents as muscle weakness, leg cramps, and fatigue. In
addition to neuromuscular issues, the nurse may see signs of decreased GI motility such as
constipation or paralytic ileus. Severe cases can lead to dangerous cardiac dysrhythmias
and respiratory failure if not treated promptly.
2. Which of the following interventions is a priority for a patient diagnosed with right-sided
heart failure?
A. Monitoring for peripheral edema
B. Assessing for pulmonary crackles
,C. Preparing for emergency intubation
D. Administering IV nitroglycerin
Correct Answer: A
Rationale: Right-sided heart failure involves the backflow of blood into the systemic
venous circulation. This results in clinical manifestations such as peripheral edema, jugular
venous distention, and hepatomegaly. The nurse must monitor weight and fluid status
closely to manage these symptoms effectively.
3. A patient is prescribed Digoxin 0.125 mg daily. The nurse should withhold the medication
and notify the provider if which of the following is noted?
A. Serum potassium level of 4.5 mEq/L
B. Apical heart rate of 54 beats per minute
C. Blood pressure of 110/70 mmHg
D. Patient reports being very hungry
Correct Answer: B
Rationale: Digoxin is a cardiac glycoside that slows the heart rate to increase the force of
contraction. Before administration, the nurse must assess the apical pulse for one full
minute and withhold the dose if it is below 60 bpm. Bradycardia is a classic sign of digoxin
toxicity and requires immediate medical attention.
, 4. A nurse is providing discharge teaching for a patient with a new prescription for Warfarin.
Which statement by the patient indicates a need for further teaching?
A. I will use an electric razor for shaving.
B. I will increase my intake of spinach and kale.
C. I should report any dark, tarry stools.
D. I will need regular blood tests for monitoring.
Correct Answer: B
Rationale: Warfarin is an anticoagulant that works by interfering with Vitamin K
dependent clotting factors. Patients should maintain a consistent intake of Vitamin K rather
than increasing or decreasing it suddenly, as this affects the medication’s efficacy. Dark
tarry stools and using a soft toothbrush are standard safety precautions for patients on this
therapy.
5. A patient with COPD is experiencing dyspnea. Which of the following positions should the
nurse encourage to improve breathing?
A. Supine position with legs elevated
B. High-Fowler’s position
C. Orthopneic or Tripod position
D. Left lateral side-lying position
Correct Answer: C
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a patient with a potassium level of 2.9 mEq/L. Which of the following
clinical manifestations should the nurse expect to assess?
A. Hyperactive deep tendon reflexes
B. Muscle weakness and leg cramps
C. Peaked T waves on the ECG
D. Diarrhea and abdominal cramping
Correct Answer: B
Rationale: Hypokalemia often presents as muscle weakness, leg cramps, and fatigue. In
addition to neuromuscular issues, the nurse may see signs of decreased GI motility such as
constipation or paralytic ileus. Severe cases can lead to dangerous cardiac dysrhythmias
and respiratory failure if not treated promptly.
2. Which of the following interventions is a priority for a patient diagnosed with right-sided
heart failure?
A. Monitoring for peripheral edema
B. Assessing for pulmonary crackles
,C. Preparing for emergency intubation
D. Administering IV nitroglycerin
Correct Answer: A
Rationale: Right-sided heart failure involves the backflow of blood into the systemic
venous circulation. This results in clinical manifestations such as peripheral edema, jugular
venous distention, and hepatomegaly. The nurse must monitor weight and fluid status
closely to manage these symptoms effectively.
3. A patient is prescribed Digoxin 0.125 mg daily. The nurse should withhold the medication
and notify the provider if which of the following is noted?
A. Serum potassium level of 4.5 mEq/L
B. Apical heart rate of 54 beats per minute
C. Blood pressure of 110/70 mmHg
D. Patient reports being very hungry
Correct Answer: B
Rationale: Digoxin is a cardiac glycoside that slows the heart rate to increase the force of
contraction. Before administration, the nurse must assess the apical pulse for one full
minute and withhold the dose if it is below 60 bpm. Bradycardia is a classic sign of digoxin
toxicity and requires immediate medical attention.
, 4. A nurse is providing discharge teaching for a patient with a new prescription for Warfarin.
Which statement by the patient indicates a need for further teaching?
A. I will use an electric razor for shaving.
B. I will increase my intake of spinach and kale.
C. I should report any dark, tarry stools.
D. I will need regular blood tests for monitoring.
Correct Answer: B
Rationale: Warfarin is an anticoagulant that works by interfering with Vitamin K
dependent clotting factors. Patients should maintain a consistent intake of Vitamin K rather
than increasing or decreasing it suddenly, as this affects the medication’s efficacy. Dark
tarry stools and using a soft toothbrush are standard safety precautions for patients on this
therapy.
5. A patient with COPD is experiencing dyspnea. Which of the following positions should the
nurse encourage to improve breathing?
A. Supine position with legs elevated
B. High-Fowler’s position
C. Orthopneic or Tripod position
D. Left lateral side-lying position
Correct Answer: C
