NUR2571/NUR 2571 Exam 1 V3 |
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is assessing a patient with a sodium level of 128 mEq/L. Which clinical
manifestation should the nurse prioritize?
A. Hyperreflexia
B. Confusion and seizures
C. Extreme thirst
D. Dry mucous membranes
Correct Answer: B
Expert Explanation: A sodium level of 128 mEq/L indicates hyponatremia, which causes
water to move into brain cells, resulting in cerebral edema. The priority assessment for
these patients is neurological status because they are at high risk for confusion, seizures,
and coma. Other symptoms like thirst are more typical of hypernatremia.
2. When reviewing ABG results, the nurse notes pH 7.50, PaCO2 30 mmHg, and HCO3 24
mEq/L. How should the nurse interpret this?
A. Metabolic acidosis
,B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: D
Expert Explanation: The pH is above 7.45, indicating alkalosis, and the PaCO2 is below 35
mmHg, indicating a respiratory cause. Since the bicarbonate level is within the normal
range, the condition is respiratory alkalosis. This is commonly caused by hyperventilation,
which blows off too much carbon dioxide.
3. A patient scheduled for surgery is confused about the procedure. What is the nurse’s
primary responsibility regarding informed consent?
A. Explain the risks and benefits of the surgery
B. Obtain the consent from a family member immediately
C. Ensure the patient signs the form even if they are unsure
D. Witness the patient’s signature and notify the surgeon
Correct Answer: D
Expert Explanation: The nurse’s role in informed consent is to act as a witness to the
signature and ensure the patient is competent. If the patient expresses confusion or lack of
knowledge, the nurse must stop and notify the surgeon to provide further explanation.
, Nurses do not provide the primary education regarding surgical risks and benefits; that is
the surgeon’s duty.
4. Which electrolyte imbalance is most likely to cause peaked T-waves on an ECG?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypokalemia
Correct Answer: C
Expert Explanation: Hyperkalemia affects the electrical activity of the heart, often leading
to peaked T-waves, widened QRS complexes, and potentially cardiac arrest. It is a medical
emergency that requires immediate intervention to shift potassium back into cells.
Monitoring ECG changes is a critical nursing action for patients with high potassium levels.
5. A nurse observes a red streak and warmth at a patient’s peripheral IV site. Which action
should the nurse take first?
A. Apply a cold compress
B. Slow the infusion rate
C. Flush the line with saline
D. Discontinue the IV line
Correct Answer: D
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is assessing a patient with a sodium level of 128 mEq/L. Which clinical
manifestation should the nurse prioritize?
A. Hyperreflexia
B. Confusion and seizures
C. Extreme thirst
D. Dry mucous membranes
Correct Answer: B
Expert Explanation: A sodium level of 128 mEq/L indicates hyponatremia, which causes
water to move into brain cells, resulting in cerebral edema. The priority assessment for
these patients is neurological status because they are at high risk for confusion, seizures,
and coma. Other symptoms like thirst are more typical of hypernatremia.
2. When reviewing ABG results, the nurse notes pH 7.50, PaCO2 30 mmHg, and HCO3 24
mEq/L. How should the nurse interpret this?
A. Metabolic acidosis
,B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: D
Expert Explanation: The pH is above 7.45, indicating alkalosis, and the PaCO2 is below 35
mmHg, indicating a respiratory cause. Since the bicarbonate level is within the normal
range, the condition is respiratory alkalosis. This is commonly caused by hyperventilation,
which blows off too much carbon dioxide.
3. A patient scheduled for surgery is confused about the procedure. What is the nurse’s
primary responsibility regarding informed consent?
A. Explain the risks and benefits of the surgery
B. Obtain the consent from a family member immediately
C. Ensure the patient signs the form even if they are unsure
D. Witness the patient’s signature and notify the surgeon
Correct Answer: D
Expert Explanation: The nurse’s role in informed consent is to act as a witness to the
signature and ensure the patient is competent. If the patient expresses confusion or lack of
knowledge, the nurse must stop and notify the surgeon to provide further explanation.
, Nurses do not provide the primary education regarding surgical risks and benefits; that is
the surgeon’s duty.
4. Which electrolyte imbalance is most likely to cause peaked T-waves on an ECG?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypokalemia
Correct Answer: C
Expert Explanation: Hyperkalemia affects the electrical activity of the heart, often leading
to peaked T-waves, widened QRS complexes, and potentially cardiac arrest. It is a medical
emergency that requires immediate intervention to shift potassium back into cells.
Monitoring ECG changes is a critical nursing action for patients with high potassium levels.
5. A nurse observes a red streak and warmth at a patient’s peripheral IV site. Which action
should the nurse take first?
A. Apply a cold compress
B. Slow the infusion rate
C. Flush the line with saline
D. Discontinue the IV line
Correct Answer: D
