NUR2571/NUR 2571 Final Exam V3
| Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is caring for a patient with left-sided heart failure. Which clinical manifestation
should the nurse prioritize in the assessment?
A. Crackles in the lung bases
B. Peripheral edema
C. Jugular venous distension
D. Ascites
Correct Answer: A
Expert Explanation: Left-sided heart failure causes blood to back up into the pulmonary
system rather than being pumped to the rest of the body. This fluid shift leads to
pulmonary congestion and adventitious breath sounds like crackles. The nurse must
prioritize respiratory assessment to monitor for worsening pulmonary edema.
2. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52, and HCO3 24. How
should the nurse interpret these findings?
A. Metabolic Acidosis
,B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: The pH is below 7.35 which indicates acidosis. The PaCO2 is elevated
above 45 mmHg which confirms a respiratory cause for the pH shift. Because the
bicarbonate is within the normal range, the condition is categorized as uncompensated
respiratory acidosis.
3. A patient with Chronic Obstructive Pulmonary Disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is typically recommended to avoid suppressing the hypoxic
drive?
A. 6-10 L/min
B. 8-12 L/min
C. 1-2 L/min
D. 10-15 L/min
Correct Answer: C
Expert Explanation: Patients with COPD often rely on a low oxygen level to stimulate their
drive to breathe. Providing high concentrations of oxygen can inadvertently suppress this
, drive and lead to respiratory arrest. Therefore, low flow rates of 1 to 2 liters per minute are
generally maintained.
4. A nurse finds a patient with Type 1 Diabetes sweating, shaky, and confused. The bedside
glucose monitor reads 48 mg/dL. What is the most appropriate immediate action?
A. Administer 10 units of regular insulin
B. Provide 15 grams of simple carbohydrates like orange juice
C. Call the healthcare provider to request a STAT BMP
D. Instruct the patient to lie down and rest
Correct Answer: B
Expert Explanation: The patient is experiencing hypoglycemia, which is a medical
emergency requiring rapid intervention. According to the 15-15 rule, the nurse should
provide 15 grams of simple sugar to raise blood glucose levels quickly. Blood glucose
should be rechecked in 15 minutes to evaluate the effectiveness of the treatment.
5. Which assessment finding is a contraindication for a patient diagnosed with an ischemic
stroke to receive tissue plasminogen activator (tPA)?
A. Blood pressure of 140/90 mmHg
B. Current intracranial hemorrhage
C. History of a minor surgical procedure 5 years ago
D. Onset of symptoms occurred 2 hours ago
| Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is caring for a patient with left-sided heart failure. Which clinical manifestation
should the nurse prioritize in the assessment?
A. Crackles in the lung bases
B. Peripheral edema
C. Jugular venous distension
D. Ascites
Correct Answer: A
Expert Explanation: Left-sided heart failure causes blood to back up into the pulmonary
system rather than being pumped to the rest of the body. This fluid shift leads to
pulmonary congestion and adventitious breath sounds like crackles. The nurse must
prioritize respiratory assessment to monitor for worsening pulmonary edema.
2. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52, and HCO3 24. How
should the nurse interpret these findings?
A. Metabolic Acidosis
,B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: The pH is below 7.35 which indicates acidosis. The PaCO2 is elevated
above 45 mmHg which confirms a respiratory cause for the pH shift. Because the
bicarbonate is within the normal range, the condition is categorized as uncompensated
respiratory acidosis.
3. A patient with Chronic Obstructive Pulmonary Disease (COPD) is receiving oxygen via nasal
cannula. Which oxygen flow rate is typically recommended to avoid suppressing the hypoxic
drive?
A. 6-10 L/min
B. 8-12 L/min
C. 1-2 L/min
D. 10-15 L/min
Correct Answer: C
Expert Explanation: Patients with COPD often rely on a low oxygen level to stimulate their
drive to breathe. Providing high concentrations of oxygen can inadvertently suppress this
, drive and lead to respiratory arrest. Therefore, low flow rates of 1 to 2 liters per minute are
generally maintained.
4. A nurse finds a patient with Type 1 Diabetes sweating, shaky, and confused. The bedside
glucose monitor reads 48 mg/dL. What is the most appropriate immediate action?
A. Administer 10 units of regular insulin
B. Provide 15 grams of simple carbohydrates like orange juice
C. Call the healthcare provider to request a STAT BMP
D. Instruct the patient to lie down and rest
Correct Answer: B
Expert Explanation: The patient is experiencing hypoglycemia, which is a medical
emergency requiring rapid intervention. According to the 15-15 rule, the nurse should
provide 15 grams of simple sugar to raise blood glucose levels quickly. Blood glucose
should be rechecked in 15 minutes to evaluate the effectiveness of the treatment.
5. Which assessment finding is a contraindication for a patient diagnosed with an ischemic
stroke to receive tissue plasminogen activator (tPA)?
A. Blood pressure of 140/90 mmHg
B. Current intracranial hemorrhage
C. History of a minor surgical procedure 5 years ago
D. Onset of symptoms occurred 2 hours ago
