NUR176/NUR 176 Exam 2 V2 | Concepts of
Adult Health Nursing for the Practical
Nurse I Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD) who is
receiving oxygen via nasal cannula. Which oxygen flow rate is most appropriate to avoid
suppressing the client’s respiratory drive?
A. 5 to 6 L/min
B. 1 to 2 L/min
C. 8 to 10 L/min
D. 12 to 15 L/min
Correct Answer: B
Rationale: In patients with chronic hypercapnia, the respiratory drive is often triggered by
low oxygen levels rather than high carbon dioxide levels. Providing high concentrations of
oxygen can eliminate this stimulus and lead to respiratory hypoventilation or arrest. The
nurse should maintain a flow rate of 1-2 L/min to keep oxygen saturation between 88%
and 92%.
2. A client is 24 hours post-abdominal surgery. Upon assessment, the nurse notes the surgical
wound has separated and internal organs are protruding. What is the priority nursing action?
A. Push the organs back into the abdominal cavity gently.
,B. Apply a dry sterile pressure dressing to the site immediately.
C. Cover the protruding organs with sterile dressings moistened with sterile normal saline.
D. Ask the client to cough to see if more organs protrude.
Correct Answer: C
Rationale: Evisceration is a medical emergency where abdominal contents protrude
through a surgical incision. The nurse must protect the exposed organs from drying and
infection by using sterile, saline-soaked dressings. The nurse should then notify the
surgeon immediately and prepare the client for emergency surgery while maintaining a
low Fowler’s position with knees flexed.
3. A nurse is reviewing arterial blood gas (ABG) results for a client with severe vomiting. The
results are: pH 7.50, PaCO2 42 mmHg, and HCO3 30 mEq/L. How should the nurse interpret
these findings?
A. Metabolic Alkalosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Respiratory Acidosis
Correct Answer: A
Rationale: The pH of 7.50 indicates alkalosis as it is above the normal range of 7.35-7.45.
The PaCO2 is within the normal range, while the HCO3 is elevated above 26 mEq/L,
, suggesting a metabolic cause. Prolonged vomiting leads to a loss of gastric acid, which
typically results in metabolic alkalosis.
4. Which clinical manifestation should the nurse expect to find in a client diagnosed with Left-
Sided Heart Failure?
A. Peripheral edema and weight gain
B. Jugular venous distention (JVD)
C. Splenomegaly and hepatomegaly
D. Crackles in the lungs and dyspnea
Correct Answer: D
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation,
leading to pulmonary congestion. Symptoms typically include crackles on auscultation,
shortness of breath, and orthopnea. In contrast, peripheral edema and JVD are
characteristic signs of right-sided heart failure.
5. A nurse is preparing to administer digoxin (Lanoxin) to a client. Which electrolyte
imbalance should the nurse monitor for, as it increases the risk of digoxin toxicity?
A. Hypernatremia
B. Hypocalcemia
C. Hypokalemia
D. Hypermagnesemia
Adult Health Nursing for the Practical
Nurse I Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD) who is
receiving oxygen via nasal cannula. Which oxygen flow rate is most appropriate to avoid
suppressing the client’s respiratory drive?
A. 5 to 6 L/min
B. 1 to 2 L/min
C. 8 to 10 L/min
D. 12 to 15 L/min
Correct Answer: B
Rationale: In patients with chronic hypercapnia, the respiratory drive is often triggered by
low oxygen levels rather than high carbon dioxide levels. Providing high concentrations of
oxygen can eliminate this stimulus and lead to respiratory hypoventilation or arrest. The
nurse should maintain a flow rate of 1-2 L/min to keep oxygen saturation between 88%
and 92%.
2. A client is 24 hours post-abdominal surgery. Upon assessment, the nurse notes the surgical
wound has separated and internal organs are protruding. What is the priority nursing action?
A. Push the organs back into the abdominal cavity gently.
,B. Apply a dry sterile pressure dressing to the site immediately.
C. Cover the protruding organs with sterile dressings moistened with sterile normal saline.
D. Ask the client to cough to see if more organs protrude.
Correct Answer: C
Rationale: Evisceration is a medical emergency where abdominal contents protrude
through a surgical incision. The nurse must protect the exposed organs from drying and
infection by using sterile, saline-soaked dressings. The nurse should then notify the
surgeon immediately and prepare the client for emergency surgery while maintaining a
low Fowler’s position with knees flexed.
3. A nurse is reviewing arterial blood gas (ABG) results for a client with severe vomiting. The
results are: pH 7.50, PaCO2 42 mmHg, and HCO3 30 mEq/L. How should the nurse interpret
these findings?
A. Metabolic Alkalosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Respiratory Acidosis
Correct Answer: A
Rationale: The pH of 7.50 indicates alkalosis as it is above the normal range of 7.35-7.45.
The PaCO2 is within the normal range, while the HCO3 is elevated above 26 mEq/L,
, suggesting a metabolic cause. Prolonged vomiting leads to a loss of gastric acid, which
typically results in metabolic alkalosis.
4. Which clinical manifestation should the nurse expect to find in a client diagnosed with Left-
Sided Heart Failure?
A. Peripheral edema and weight gain
B. Jugular venous distention (JVD)
C. Splenomegaly and hepatomegaly
D. Crackles in the lungs and dyspnea
Correct Answer: D
Rationale: Left-sided heart failure causes blood to back up into the pulmonary circulation,
leading to pulmonary congestion. Symptoms typically include crackles on auscultation,
shortness of breath, and orthopnea. In contrast, peripheral edema and JVD are
characteristic signs of right-sided heart failure.
5. A nurse is preparing to administer digoxin (Lanoxin) to a client. Which electrolyte
imbalance should the nurse monitor for, as it increases the risk of digoxin toxicity?
A. Hypernatremia
B. Hypocalcemia
C. Hypokalemia
D. Hypermagnesemia
