NUR2571/NUR 2571 Exam 1 V2 |
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A patient presents with a serum potassium level of 2.8 mEq/L. Which assessment finding
should the nurse prioritize?
A. Elevated blood pressure
B. Increased bowel sounds
C. Cardiac dysrhythmias
D. Hyperactive deep tendon reflexes
Correct Answer: C
Expert Explanation: Hypokalemia significantly affects cardiac electrical conduction,
potentially leading to lethal dysrhythmias. The nurse must prioritize cardiac monitoring to
detect changes like U-waves or flattened T-waves early. Other symptoms may include
muscle weakness and decreased gastrointestinal motility, but cardiac safety is the highest
priority.
2. Which of the following patients is at the highest risk for developing hyponatremia?
A. A patient with prolonged diaphoresis and high water intake
,B. A patient with excessive wound drainage
C. A patient with diabetes insipidus
D. A patient receiving a hypertonic tube feeding
Correct Answer: A
Expert Explanation: Hyponatremia often occurs when sodium is lost through sweating
and replaced only by plain water, which dilutes the remaining sodium. This condition can
lead to cellular swelling, particularly in the brain, causing neurological symptoms. Nurses
should monitor for confusion, seizures, and muscle twitching in these high-risk patients.
3. The nurse is interpreting ABG results: pH 7.31, PaCO2 50 mmHg, HCO3 24 mEq/L. Which
acid-base imbalance is present?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg
indicates a respiratory cause. Because the bicarbonate is within the normal range, the
condition is uncompensated respiratory acidosis. This state is common in patients with
hypoventilation or obstructive lung diseases.
, 4. A nurse is caring for a patient scheduled for surgery. What is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Obtaining the patient’s signature and witnessing it
C. Providing details about alternative treatments
D. Deciding if the patient is mentally competent to sign
Correct Answer: B
Expert Explanation: The nurse’s role in informed consent is to witness the patient’s
signature and verify that the patient appears competent and signed voluntarily. It is the
surgeon’s legal responsibility to explain the procedure, risks, and alternatives. If the patient
has questions about the surgery itself, the nurse must contact the surgeon to provide
further clarification.
5. During a procedure, a patient develops tachycardia, muscle rigidity, and a rapidly rising
temperature. Which medication should the nurse expect to administer?
A. Naloxone
B. Epinephrine
C. Dantrolene sodium
D. Atropine sulfate
Correct Answer: C
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A patient presents with a serum potassium level of 2.8 mEq/L. Which assessment finding
should the nurse prioritize?
A. Elevated blood pressure
B. Increased bowel sounds
C. Cardiac dysrhythmias
D. Hyperactive deep tendon reflexes
Correct Answer: C
Expert Explanation: Hypokalemia significantly affects cardiac electrical conduction,
potentially leading to lethal dysrhythmias. The nurse must prioritize cardiac monitoring to
detect changes like U-waves or flattened T-waves early. Other symptoms may include
muscle weakness and decreased gastrointestinal motility, but cardiac safety is the highest
priority.
2. Which of the following patients is at the highest risk for developing hyponatremia?
A. A patient with prolonged diaphoresis and high water intake
,B. A patient with excessive wound drainage
C. A patient with diabetes insipidus
D. A patient receiving a hypertonic tube feeding
Correct Answer: A
Expert Explanation: Hyponatremia often occurs when sodium is lost through sweating
and replaced only by plain water, which dilutes the remaining sodium. This condition can
lead to cellular swelling, particularly in the brain, causing neurological symptoms. Nurses
should monitor for confusion, seizures, and muscle twitching in these high-risk patients.
3. The nurse is interpreting ABG results: pH 7.31, PaCO2 50 mmHg, HCO3 24 mEq/L. Which
acid-base imbalance is present?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg
indicates a respiratory cause. Because the bicarbonate is within the normal range, the
condition is uncompensated respiratory acidosis. This state is common in patients with
hypoventilation or obstructive lung diseases.
, 4. A nurse is caring for a patient scheduled for surgery. What is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Obtaining the patient’s signature and witnessing it
C. Providing details about alternative treatments
D. Deciding if the patient is mentally competent to sign
Correct Answer: B
Expert Explanation: The nurse’s role in informed consent is to witness the patient’s
signature and verify that the patient appears competent and signed voluntarily. It is the
surgeon’s legal responsibility to explain the procedure, risks, and alternatives. If the patient
has questions about the surgery itself, the nurse must contact the surgeon to provide
further clarification.
5. During a procedure, a patient develops tachycardia, muscle rigidity, and a rapidly rising
temperature. Which medication should the nurse expect to administer?
A. Naloxone
B. Epinephrine
C. Dantrolene sodium
D. Atropine sulfate
Correct Answer: C
