NUR2571/NUR 2571 Final Exam V1
| Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A patient with heart failure is prescribed digoxin. Which of the following assessment
findings would most likely indicate digoxin toxicity?
A. Increased urine output
B. Tachycardia and hypertension
C. Hyperkalemia
D. Visual disturbances, such as seeing yellow halos
Correct Answer: D
Expert Explanation: Digoxin toxicity frequently presents with gastrointestinal symptoms
and visual changes. Yellow or green halos around lights are a classic sign of this condition.
The nurse must also monitor for bradycardia and check serum digoxin levels if toxicity is
suspected.
2. A nurse is caring for a client who has sustained deep-partial thickness burns to 40% of their
body. Which phase of burn management is the nurse’s priority during the first 24 hours?
A. Rehabilitative phase
,B. Resuscitative phase
C. Acute phase
D. Restorative phase
Correct Answer: B
Expert Explanation: The resuscitative phase occurs from the time of injury to
approximately 48 to 72 hours later. During this time, the primary focus is on fluid
replacement and maintaining organ perfusion. Prevention of hypovolemic shock is the
highest nursing priority during this initial window.
3. A nurse interprets the following ABG results: pH 7.30, PaCO2 50 mmHg, HCO3 26 mEq/L.
How should the nurse document these results?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Respiratory acidosis
Correct Answer: D
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 not compensated. This clinical picture is typical of hypoventilation or
obstructive lung disease.
, 4. Which clinical manifestation should a nurse expect to see in a patient experiencing the
compensatory stage of shock?
A. Increased heart rate and cool, clammy skin
B. Anuria
C. Lethargy
D. Bradycardia
Correct Answer: A
Expert Explanation: In the compensatory stage of shock, the body activates the
sympathetic nervous system to maintain cardiac output. This results in tachycardia and
peripheral vasoconstriction, leading to cool and clammy skin. The blood pressure may
remain within normal limits initially due to these mechanisms.
5. A nurse is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which task is
appropriate to delegate?
A. Evaluating a patient’s pain level after medication
B. Developing a plan of care for a new admission
C. Assisting a stable patient with ambulation
D. Teaching a patient how to use an incentive spirometer
Correct Answer: C
| Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A patient with heart failure is prescribed digoxin. Which of the following assessment
findings would most likely indicate digoxin toxicity?
A. Increased urine output
B. Tachycardia and hypertension
C. Hyperkalemia
D. Visual disturbances, such as seeing yellow halos
Correct Answer: D
Expert Explanation: Digoxin toxicity frequently presents with gastrointestinal symptoms
and visual changes. Yellow or green halos around lights are a classic sign of this condition.
The nurse must also monitor for bradycardia and check serum digoxin levels if toxicity is
suspected.
2. A nurse is caring for a client who has sustained deep-partial thickness burns to 40% of their
body. Which phase of burn management is the nurse’s priority during the first 24 hours?
A. Rehabilitative phase
,B. Resuscitative phase
C. Acute phase
D. Restorative phase
Correct Answer: B
Expert Explanation: The resuscitative phase occurs from the time of injury to
approximately 48 to 72 hours later. During this time, the primary focus is on fluid
replacement and maintaining organ perfusion. Prevention of hypovolemic shock is the
highest nursing priority during this initial window.
3. A nurse interprets the following ABG results: pH 7.30, PaCO2 50 mmHg, HCO3 26 mEq/L.
How should the nurse document these results?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Respiratory acidosis
Correct Answer: D
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 not compensated. This clinical picture is typical of hypoventilation or
obstructive lung disease.
, 4. Which clinical manifestation should a nurse expect to see in a patient experiencing the
compensatory stage of shock?
A. Increased heart rate and cool, clammy skin
B. Anuria
C. Lethargy
D. Bradycardia
Correct Answer: A
Expert Explanation: In the compensatory stage of shock, the body activates the
sympathetic nervous system to maintain cardiac output. This results in tachycardia and
peripheral vasoconstriction, leading to cool and clammy skin. The blood pressure may
remain within normal limits initially due to these mechanisms.
5. A nurse is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which task is
appropriate to delegate?
A. Evaluating a patient’s pain level after medication
B. Developing a plan of care for a new admission
C. Assisting a stable patient with ambulation
D. Teaching a patient how to use an incentive spirometer
Correct Answer: C
