NUR2571/NUR 2571 Exam 3 V2 |
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is assessing a client with right-sided heart failure. Which of the following findings
should the nurse expect?
A. Pulmonary congestion
B. Crackles in the lungs
C. Orthopnea
D. Jugular venous distension
Correct Answer: D
Expert Explanation: Right-sided heart failure leads to systemic venous congestion
because the right ventricle cannot pump blood effectively into the lungs. This causes blood
to back up into the systemic circulation, resulting in jugular venous distension, peripheral
edema, and hepatomegaly. Pulmonary congestion and crackles are characteristic findings
of left-sided heart failure.
2. A client is diagnosed with pernicious anemia. The nurse understands that this condition is
caused by a deficiency in which substance?
A. Iron
,B. Erythropoietin
C. Folic acid
D. Intrinsic factor
Correct Answer: D
Expert Explanation: Pernicious anemia occurs when the gastric mucosa fails to produce
intrinsic factor, which is necessary for the absorption of vitamin B12. Without vitamin B12,
the body cannot produce healthy red blood cells. Treatment usually involves lifelong
vitamin B12 injections to bypass the gastrointestinal tract.
3. Which clinical manifestation is a hallmark sign of a sickle cell crisis?
A. Polycythemia
B. Bradycardia
C. Hypotension
D. Severe pain
Correct Answer: D
Expert Explanation: A sickle cell crisis involves the clumping of sickled red blood cells,
which obstructs blood flow to tissues and organs. This vaso-occlusion causes severe,
excruciating pain and potential tissue ischemia. Management focuses on hydration,
oxygenation, and aggressive pain control.
, 4. A nurse is caring for a client with COPD who is receiving oxygen therapy. Why is it
important to maintain oxygen flow at a low rate for this client?
A. To prevent oxygen toxicity
B. To avoid suppressing the hypoxic drive
C. To reduce the risk of combustion
D. To prevent drying of the nasal mucosa
Correct Answer: B
Expert Explanation: In chronic COPD, the body often becomes accustomed to high levels
of carbon dioxide, making low oxygen levels the primary stimulus for breathing. Providing
too much oxygen can suppress this hypoxic drive, potentially leading to respiratory arrest.
Nurses must carefully monitor pulse oximetry and respiratory rate in these patients.
5. Which laboratory value is the most sensitive indicator of acute pancreatitis?
A. Serum amylase
B. Blood urea nitrogen
C. Serum lipase
D. White blood cell count
Correct Answer: C
Expert Explanation: Serum lipase is considered more specific and stays elevated longer
than amylase in cases of acute pancreatitis. While amylase rises quickly, it also returns to
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A nurse is assessing a client with right-sided heart failure. Which of the following findings
should the nurse expect?
A. Pulmonary congestion
B. Crackles in the lungs
C. Orthopnea
D. Jugular venous distension
Correct Answer: D
Expert Explanation: Right-sided heart failure leads to systemic venous congestion
because the right ventricle cannot pump blood effectively into the lungs. This causes blood
to back up into the systemic circulation, resulting in jugular venous distension, peripheral
edema, and hepatomegaly. Pulmonary congestion and crackles are characteristic findings
of left-sided heart failure.
2. A client is diagnosed with pernicious anemia. The nurse understands that this condition is
caused by a deficiency in which substance?
A. Iron
,B. Erythropoietin
C. Folic acid
D. Intrinsic factor
Correct Answer: D
Expert Explanation: Pernicious anemia occurs when the gastric mucosa fails to produce
intrinsic factor, which is necessary for the absorption of vitamin B12. Without vitamin B12,
the body cannot produce healthy red blood cells. Treatment usually involves lifelong
vitamin B12 injections to bypass the gastrointestinal tract.
3. Which clinical manifestation is a hallmark sign of a sickle cell crisis?
A. Polycythemia
B. Bradycardia
C. Hypotension
D. Severe pain
Correct Answer: D
Expert Explanation: A sickle cell crisis involves the clumping of sickled red blood cells,
which obstructs blood flow to tissues and organs. This vaso-occlusion causes severe,
excruciating pain and potential tissue ischemia. Management focuses on hydration,
oxygenation, and aggressive pain control.
, 4. A nurse is caring for a client with COPD who is receiving oxygen therapy. Why is it
important to maintain oxygen flow at a low rate for this client?
A. To prevent oxygen toxicity
B. To avoid suppressing the hypoxic drive
C. To reduce the risk of combustion
D. To prevent drying of the nasal mucosa
Correct Answer: B
Expert Explanation: In chronic COPD, the body often becomes accustomed to high levels
of carbon dioxide, making low oxygen levels the primary stimulus for breathing. Providing
too much oxygen can suppress this hypoxic drive, potentially leading to respiratory arrest.
Nurses must carefully monitor pulse oximetry and respiratory rate in these patients.
5. Which laboratory value is the most sensitive indicator of acute pancreatitis?
A. Serum amylase
B. Blood urea nitrogen
C. Serum lipase
D. White blood cell count
Correct Answer: C
Expert Explanation: Serum lipase is considered more specific and stays elevated longer
than amylase in cases of acute pancreatitis. While amylase rises quickly, it also returns to
