NUR2571/NUR 2571 Final Exam V2
| Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A patient with Type 1 Diabetes is found sweaty, shaky, and confused. What is the priority
nursing action?
A. Administer 15g of simple carbohydrates.
B. Check the patient’s blood pressure.
C. Call the physician immediately.
D. Give a dose of rapid-acting insulin.
Correct Answer: A
Expert Explanation: The patient is exhibiting classic signs of hypoglycemia, which
requires immediate glucose replacement. Providing 15 grams of simple carbohydrates is
the standard first-line treatment for a conscious patient. After treatment, the nurse should
recheck blood glucose levels in 15 minutes to evaluate effectiveness.
2. Which assessment finding is most characteristic of left-sided heart failure?
A. Crackles in the lung bases
B. Jugular venous distention
,C. Dependent peripheral edema
D. Hepatic congestion
Correct Answer: A
Expert Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation. This leads to pulmonary congestion, which is manifested by crackles heard
during lung auscultation. In contrast, right-sided heart failure typically causes systemic
symptoms like jugular vein distention and peripheral edema.
3. A nurse is assessing a patient with a leg cast and notes the patient cannot move their toes
and has severe pain unrelieved by morphine. What should the nurse suspect?
A. Compartment syndrome
B. Deep vein thrombosis
C. Normal post-operative pain
D. Osteomyelitis
Correct Answer: A
Expert Explanation: Compartment syndrome is a medical emergency characterized by
increased pressure within a muscle compartment. The inability to move digits and pain out
of proportion to the injury are classic red flags. The nurse must notify the provider
immediately to prevent permanent nerve and muscle damage.
, 4. What is the most effective way to prevent deep vein thrombosis (DVT) in a post-operative
patient?
A. Encouraging bed rest for 24 hours
B. Limiting fluid intake
C. Massaging the calves twice daily
D. Early and frequent ambulation
Correct Answer: D
Expert Explanation: Ambulation promotes venous return and prevents the stasis of blood
in the lower extremities. This is considered the gold standard for DVT prevention in
surgical patients. Massaging the calves is contraindicated because it could dislodge an
existing clot and cause a pulmonary embolism.
5. Which task is most appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
A. Evaluating the effectiveness of pain medication
B. Assisting a stable patient with a bed bath
C. Developing a plan of care for a new admission
D. Teaching a patient how to use an incentive spirometer
Correct Answer: B
| Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A patient with Type 1 Diabetes is found sweaty, shaky, and confused. What is the priority
nursing action?
A. Administer 15g of simple carbohydrates.
B. Check the patient’s blood pressure.
C. Call the physician immediately.
D. Give a dose of rapid-acting insulin.
Correct Answer: A
Expert Explanation: The patient is exhibiting classic signs of hypoglycemia, which
requires immediate glucose replacement. Providing 15 grams of simple carbohydrates is
the standard first-line treatment for a conscious patient. After treatment, the nurse should
recheck blood glucose levels in 15 minutes to evaluate effectiveness.
2. Which assessment finding is most characteristic of left-sided heart failure?
A. Crackles in the lung bases
B. Jugular venous distention
,C. Dependent peripheral edema
D. Hepatic congestion
Correct Answer: A
Expert Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation. This leads to pulmonary congestion, which is manifested by crackles heard
during lung auscultation. In contrast, right-sided heart failure typically causes systemic
symptoms like jugular vein distention and peripheral edema.
3. A nurse is assessing a patient with a leg cast and notes the patient cannot move their toes
and has severe pain unrelieved by morphine. What should the nurse suspect?
A. Compartment syndrome
B. Deep vein thrombosis
C. Normal post-operative pain
D. Osteomyelitis
Correct Answer: A
Expert Explanation: Compartment syndrome is a medical emergency characterized by
increased pressure within a muscle compartment. The inability to move digits and pain out
of proportion to the injury are classic red flags. The nurse must notify the provider
immediately to prevent permanent nerve and muscle damage.
, 4. What is the most effective way to prevent deep vein thrombosis (DVT) in a post-operative
patient?
A. Encouraging bed rest for 24 hours
B. Limiting fluid intake
C. Massaging the calves twice daily
D. Early and frequent ambulation
Correct Answer: D
Expert Explanation: Ambulation promotes venous return and prevents the stasis of blood
in the lower extremities. This is considered the gold standard for DVT prevention in
surgical patients. Massaging the calves is contraindicated because it could dislodge an
existing clot and cause a pulmonary embolism.
5. Which task is most appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
A. Evaluating the effectiveness of pain medication
B. Assisting a stable patient with a bed bath
C. Developing a plan of care for a new admission
D. Teaching a patient how to use an incentive spirometer
Correct Answer: B
