NUR2571/NUR 2571 Exam 4 V3 |
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A patient presents with a pH of 7.25, a PaCO2 of 55 mmHg, and a HCO3 of 24 mEq/L. Which
acid-base imbalance is occurring?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Expert Explanation: The pH of 7.25 is below the normal range of 7.35-7.45, indicating
acidosis. The PaCO2 is elevated above 45 mmHg, which points toward a respiratory cause
for the low pH. Since the bicarbonate level is normal, this confirms uncompensated
respiratory acidosis.
2. Which clinical manifestation is a hallmark sign of the ‘early’ or hyperdynamic phase of
septic shock?
A. Cold, clammy skin
,B. Bradycardia
C. Hypothermia
D. Warm, flushed skin
Correct Answer: D
Expert Explanation: In the early phase of septic shock, also known as warm shock,
peripheral vasodilation occurs. This results in warm, flushed skin and a high cardiac
output. As the shock progresses to the cold phase, the skin becomes cool and mottled due
to vasoconstriction.
3. A patient with Diabetic Ketoacidosis (DKA) is being treated. Which electrolyte must the
nurse monitor most closely when administering intravenous insulin?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Correct Answer: C
Expert Explanation: Insulin administration causes potassium to shift from the
extracellular fluid into the intracellular compartment. This can lead to a rapid drop in
serum potassium levels, potentially causing life-threatening arrhythmias. Continuous
monitoring and replacement of potassium are essential during DKA management.
, 4. A client is admitted with a suspected spinal cord injury at T6. Which complication is the
nurse most concerned about during the first 24 hours?
A. Autonomic Dysreflexia
B. Pressure Ulcers
C. Spinal Shock
D. Neurogenic Shock
Correct Answer: D
Expert Explanation: Neurogenic shock occurs within 24 hours of a high thoracic or
cervical injury and results in loss of sympathetic tone. This leads to hypotension and
bradycardia, which can compromise organ perfusion. Autonomic dysreflexia typically
occurs later after the phase of spinal shock has resolved.
5. When assessing a patient with a chest tube, the nurse notes continuous bubbling in the
water-seal chamber. What is the most likely cause?
A. Normal operation
B. An air leak in the system
C. The lung has fully expanded
D. Excessive suction is applied
Correct Answer: B
Professional Nursing II / PN2 Q&A
with Rationale | Rasmussen
University
1. A patient presents with a pH of 7.25, a PaCO2 of 55 mmHg, and a HCO3 of 24 mEq/L. Which
acid-base imbalance is occurring?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Expert Explanation: The pH of 7.25 is below the normal range of 7.35-7.45, indicating
acidosis. The PaCO2 is elevated above 45 mmHg, which points toward a respiratory cause
for the low pH. Since the bicarbonate level is normal, this confirms uncompensated
respiratory acidosis.
2. Which clinical manifestation is a hallmark sign of the ‘early’ or hyperdynamic phase of
septic shock?
A. Cold, clammy skin
,B. Bradycardia
C. Hypothermia
D. Warm, flushed skin
Correct Answer: D
Expert Explanation: In the early phase of septic shock, also known as warm shock,
peripheral vasodilation occurs. This results in warm, flushed skin and a high cardiac
output. As the shock progresses to the cold phase, the skin becomes cool and mottled due
to vasoconstriction.
3. A patient with Diabetic Ketoacidosis (DKA) is being treated. Which electrolyte must the
nurse monitor most closely when administering intravenous insulin?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Correct Answer: C
Expert Explanation: Insulin administration causes potassium to shift from the
extracellular fluid into the intracellular compartment. This can lead to a rapid drop in
serum potassium levels, potentially causing life-threatening arrhythmias. Continuous
monitoring and replacement of potassium are essential during DKA management.
, 4. A client is admitted with a suspected spinal cord injury at T6. Which complication is the
nurse most concerned about during the first 24 hours?
A. Autonomic Dysreflexia
B. Pressure Ulcers
C. Spinal Shock
D. Neurogenic Shock
Correct Answer: D
Expert Explanation: Neurogenic shock occurs within 24 hours of a high thoracic or
cervical injury and results in loss of sympathetic tone. This leads to hypotension and
bradycardia, which can compromise organ perfusion. Autonomic dysreflexia typically
occurs later after the phase of spinal shock has resolved.
5. When assessing a patient with a chest tube, the nurse notes continuous bubbling in the
water-seal chamber. What is the most likely cause?
A. Normal operation
B. An air leak in the system
C. The lung has fully expanded
D. Excessive suction is applied
Correct Answer: B
