NUR185/NUR 185 Exam 2 V1 | Concepts of
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a client with left-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Peripheral edema in the lower extremities
C. Crackles auscultated in the lung bases
D. Hepatomegaly and abdominal tenderness
Correct Answer: C
Rationale: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot pump blood efficiently into the systemic circulation. This backup causes
fluid to accumulate in the lungs, leading to crackles, dyspnea, and orthopnea. Signs like
jugular venous distention and peripheral edema are more characteristic of right-sided
heart failure.
2. A client is prescribed Digoxin for the management of heart failure. Which laboratory value
should the nurse prioritize checking before administration?
A. Serum Sodium
,B. Serum Potassium
C. Blood Urea Nitrogen (BUN)
D. Serum Calcium
Correct Answer: B
Rationale: Hypokalemia significantly increases the risk of digoxin toxicity, making serum
potassium monitoring a priority for the nurse. The nurse must ensure potassium levels are
within the normal range to prevent life-threatening cardiac dysrhythmias. While other
electrolytes are important, potassium has the most direct impact on digoxin’s safety profile.
3. Which arterial blood gas (ABG) result is most indicative of respiratory acidosis?
A. pH 7.32, PaCO2 50, HCO3 24
B. pH 7.48, PaCO2 30, HCO3 22
C. pH 7.25, PaCO2 35, HCO3 18
D. pH 7.50, PaCO2 40, HCO3 30
Correct Answer: A
Rationale: Respiratory acidosis is characterized by a low pH (below 7.35) and a high
PaCO2 (above 45 mmHg). In this case, the pH of 7.32 and PaCO2 of 50 demonstrate that the
lungs are retaining carbon dioxide. Option C represents metabolic acidosis due to the low
bicarbonate levels.
, 4. A client with Chronic Obstructive Pulmonary Disease (COPD) is being discharged. Which
breathing technique should the nurse teach to help the client manage dyspnea?
A. Rapid, shallow breathing
B. Pursed-lip breathing
C. Chest-breathing using intercostal muscles
D. Holding the breath after inspiration
Correct Answer: B
Rationale: Pursed-lip breathing helps keep the airways open longer by creating positive
pressure during expiration. This technique allows the client to expel more trapped air and
reduces the work of breathing. It is a fundamental intervention taught to COPD patients to
manage acute shortness of breath.
5. A client presents with chest pain that occurs at rest and is not relieved by nitroglycerin. The
nurse recognizes this as a characteristic of:
A. Stable Angina
B. Variant Angina
C. Unstable Angina
D. Silent Ischemia
Correct Answer: C
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a client with left-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Peripheral edema in the lower extremities
C. Crackles auscultated in the lung bases
D. Hepatomegaly and abdominal tenderness
Correct Answer: C
Rationale: Left-sided heart failure results in pulmonary congestion because the left
ventricle cannot pump blood efficiently into the systemic circulation. This backup causes
fluid to accumulate in the lungs, leading to crackles, dyspnea, and orthopnea. Signs like
jugular venous distention and peripheral edema are more characteristic of right-sided
heart failure.
2. A client is prescribed Digoxin for the management of heart failure. Which laboratory value
should the nurse prioritize checking before administration?
A. Serum Sodium
,B. Serum Potassium
C. Blood Urea Nitrogen (BUN)
D. Serum Calcium
Correct Answer: B
Rationale: Hypokalemia significantly increases the risk of digoxin toxicity, making serum
potassium monitoring a priority for the nurse. The nurse must ensure potassium levels are
within the normal range to prevent life-threatening cardiac dysrhythmias. While other
electrolytes are important, potassium has the most direct impact on digoxin’s safety profile.
3. Which arterial blood gas (ABG) result is most indicative of respiratory acidosis?
A. pH 7.32, PaCO2 50, HCO3 24
B. pH 7.48, PaCO2 30, HCO3 22
C. pH 7.25, PaCO2 35, HCO3 18
D. pH 7.50, PaCO2 40, HCO3 30
Correct Answer: A
Rationale: Respiratory acidosis is characterized by a low pH (below 7.35) and a high
PaCO2 (above 45 mmHg). In this case, the pH of 7.32 and PaCO2 of 50 demonstrate that the
lungs are retaining carbon dioxide. Option C represents metabolic acidosis due to the low
bicarbonate levels.
, 4. A client with Chronic Obstructive Pulmonary Disease (COPD) is being discharged. Which
breathing technique should the nurse teach to help the client manage dyspnea?
A. Rapid, shallow breathing
B. Pursed-lip breathing
C. Chest-breathing using intercostal muscles
D. Holding the breath after inspiration
Correct Answer: B
Rationale: Pursed-lip breathing helps keep the airways open longer by creating positive
pressure during expiration. This technique allows the client to expel more trapped air and
reduces the work of breathing. It is a fundamental intervention taught to COPD patients to
manage acute shortness of breath.
5. A client presents with chest pain that occurs at rest and is not relieved by nitroglycerin. The
nurse recognizes this as a characteristic of:
A. Stable Angina
B. Variant Angina
C. Unstable Angina
D. Silent Ischemia
Correct Answer: C
