PN2 Final Exam
1. A nurse is evaluating a patient who is being treated for dehydration. Which assessment
result does the nurse correlate with a therapeutic response to the treatment plan?
- Decreased orthostatic light-headedness and dizziness
2. After teaching a patient who is prescribed a restricted sodium diet, a nurse assesses the
patient's understanding. Which food choice for lunch indicates that the patient correctly
understood the teaching?
- Grilled chicken breast with glazed carrots
3. A nurse is assessing a patient with hypokalemia, and notes that the patient's handgrip
strength has diminished since the previous assessment 1 hour ago. What action does
the nurse take first?
- Assess the patient's respiratory rate, rhythm, and depth.
4. After teaching a patient to increase dietary potassium intake, a nurse assesses the
patient's understanding. Which dietary meal selection indicates that the patient
correctly understands the teaching?
- Sausage, one slice of whole-wheat toast, half cup of raisins (120 gm), and a glass of
milk
5. A patient at risk for developing hyperkalemia states, "I love fruit and usually eat it every
day, but now I can't because of my high potassium level." How will the nurse respond?
- "Berries, cherries, apples, and peaches are low in potassium."
6. A nurse is caring for a patient who has a serum calcium level of 14 mg/dL (3.5 mmol/L).
Which provider order does the nurse implement first?
- Connect the patient to a cardiac monitor.
,7. A nurse assesses a patient who is experiencing an acid-base imbalance. The patient's
arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3- 19
mEq/L (19 mmol/L). Which assessment would the nurse perform first?
- Cardiac rate and rhythm
8. A nurse assesses a patient who is prescribed furosemide (Lasix) for hypertension. For
which acid-base imbalance does the nurse assess to prevent complications of this
therapy?
- Metabolic alkalosis
9. A nurse is caring for a patient who is experiencing excessive diarrhea. The patient's
arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3- 16
mEq/L (16 mmol/L). Which provider order does the nurse expect to receive?
- Sodium bicarbonate 100 mEq diluted in 1 L of D5W
10. A nurse evaluates a patient's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg,
PaCO2 55 mm Hg, and HCO3- 22 mEq/L (22 mmol/L). Which intervention does the nurse
implement first?
- Assess the airway
11. A diabetic patient becomes septic after a bowel resection and is having problems with
respiratory distress. The nurse reviews the labs and finds the following ABG results: pH
7.50; PaCO2 30; HCO3: 24; and PaO2 68. What does the nurse recognize as the primary
factor causing this the acid-base imbalance?
- Hyperventilation due to poor oxygenation
12. A patient with human immune deficiency virus is admitted to the hospital with fever,
night sweats, and severe cough. Laboratory results include a CD4+ cell count of
180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the
nurse take first?
, - Place the patient under Airborne Precautions.
13. A patient with human immune deficiency virus (HIV) has had a sudden decline in status
with a large increase in viral load. What action would the nurse take first?
- Assess the patient for adherence to the drug regimen.
14. A nurse works on a unit that has admitted its first patient with acquired immune
deficiency syndrome. The nurse overhears other staff members talking about the "AIDS
guy" and wondering how the patient contracted the disease. What action by the nurse is
best?
- Confront the staff members about unethical behavior.
15. A patient with human immune deficiency virus infection is hospitalized for an unrelated
condition, and several medications are prescribed in addition to the regimen already
being used. What action by the nurse is most important?
- Consult with the pharmacy about drug interactions.
16. A nurse cares for a patient with arthritis who reports frequent asthma attacks. What
action would the nurse take first?
- Ask about medications the patient is currently taking. "I will take this medication every
morning to help prevent an acute attack."
17. A nurse cares for a patient who has a chest tube. When would this patient be at highest
risk for developing a pneumothorax?
- When the tube becomes disconnected from the drainage system
18. A nurse cares for a patient with a 40-year smoking history who is experiencing distended
neck veins and dependent edema. Which physiologic process would the nurse correlate
with this patient's history and clinical manifestations?
- Increased pulmonary pressure creating a higher workload on the right side of the heart
1. A nurse is evaluating a patient who is being treated for dehydration. Which assessment
result does the nurse correlate with a therapeutic response to the treatment plan?
- Decreased orthostatic light-headedness and dizziness
2. After teaching a patient who is prescribed a restricted sodium diet, a nurse assesses the
patient's understanding. Which food choice for lunch indicates that the patient correctly
understood the teaching?
- Grilled chicken breast with glazed carrots
3. A nurse is assessing a patient with hypokalemia, and notes that the patient's handgrip
strength has diminished since the previous assessment 1 hour ago. What action does
the nurse take first?
- Assess the patient's respiratory rate, rhythm, and depth.
4. After teaching a patient to increase dietary potassium intake, a nurse assesses the
patient's understanding. Which dietary meal selection indicates that the patient
correctly understands the teaching?
- Sausage, one slice of whole-wheat toast, half cup of raisins (120 gm), and a glass of
milk
5. A patient at risk for developing hyperkalemia states, "I love fruit and usually eat it every
day, but now I can't because of my high potassium level." How will the nurse respond?
- "Berries, cherries, apples, and peaches are low in potassium."
6. A nurse is caring for a patient who has a serum calcium level of 14 mg/dL (3.5 mmol/L).
Which provider order does the nurse implement first?
- Connect the patient to a cardiac monitor.
,7. A nurse assesses a patient who is experiencing an acid-base imbalance. The patient's
arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3- 19
mEq/L (19 mmol/L). Which assessment would the nurse perform first?
- Cardiac rate and rhythm
8. A nurse assesses a patient who is prescribed furosemide (Lasix) for hypertension. For
which acid-base imbalance does the nurse assess to prevent complications of this
therapy?
- Metabolic alkalosis
9. A nurse is caring for a patient who is experiencing excessive diarrhea. The patient's
arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3- 16
mEq/L (16 mmol/L). Which provider order does the nurse expect to receive?
- Sodium bicarbonate 100 mEq diluted in 1 L of D5W
10. A nurse evaluates a patient's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg,
PaCO2 55 mm Hg, and HCO3- 22 mEq/L (22 mmol/L). Which intervention does the nurse
implement first?
- Assess the airway
11. A diabetic patient becomes septic after a bowel resection and is having problems with
respiratory distress. The nurse reviews the labs and finds the following ABG results: pH
7.50; PaCO2 30; HCO3: 24; and PaO2 68. What does the nurse recognize as the primary
factor causing this the acid-base imbalance?
- Hyperventilation due to poor oxygenation
12. A patient with human immune deficiency virus is admitted to the hospital with fever,
night sweats, and severe cough. Laboratory results include a CD4+ cell count of
180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the
nurse take first?
, - Place the patient under Airborne Precautions.
13. A patient with human immune deficiency virus (HIV) has had a sudden decline in status
with a large increase in viral load. What action would the nurse take first?
- Assess the patient for adherence to the drug regimen.
14. A nurse works on a unit that has admitted its first patient with acquired immune
deficiency syndrome. The nurse overhears other staff members talking about the "AIDS
guy" and wondering how the patient contracted the disease. What action by the nurse is
best?
- Confront the staff members about unethical behavior.
15. A patient with human immune deficiency virus infection is hospitalized for an unrelated
condition, and several medications are prescribed in addition to the regimen already
being used. What action by the nurse is most important?
- Consult with the pharmacy about drug interactions.
16. A nurse cares for a patient with arthritis who reports frequent asthma attacks. What
action would the nurse take first?
- Ask about medications the patient is currently taking. "I will take this medication every
morning to help prevent an acute attack."
17. A nurse cares for a patient who has a chest tube. When would this patient be at highest
risk for developing a pneumothorax?
- When the tube becomes disconnected from the drainage system
18. A nurse cares for a patient with a 40-year smoking history who is experiencing distended
neck veins and dependent edema. Which physiologic process would the nurse correlate
with this patient's history and clinical manifestations?
- Increased pulmonary pressure creating a higher workload on the right side of the heart
