NURS 4581 Nursing of Adults with Complex
Needs Exam 2 Questions And Correct Answers
(Verified Answers) Plus Rationale 2027 Q&A|
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1. A nurse is caring for a client admitted with acute decompensated
heart failure. Which assessment finding requires immediate
intervention?
A. Bilateral ankle edema
B. Weight gain of 2 lb (0.9 kg) in 24 hours
C. Crackles throughout both lung fields and oxygen saturation of 84%
D. Jugular venous distention
Answer: C. Crackles throughout both lung fields and oxygen saturation
of 84%
Rationale: Diffuse crackles accompanied by severe hypoxemia indicate
acute pulmonary edema and impaired gas exchange, which is life-
threatening. Airway and oxygenation always take priority according to
the ABCs. Peripheral edema, weight gain, and jugular venous distention
,indicate worsening heart failure but are not as immediately life-
threatening as severe respiratory compromise.
2. Which laboratory value should concern the nurse most for a client
receiving intravenous heparin?
A. Platelet count of 45,000/mm³
B. Sodium of 138 mEq/L
C. Potassium of 4.0 mEq/L
D. Hemoglobin of 13 g/dL
Answer: A. Platelet count of 45,000/mm³
Rationale: A significantly decreased platelet count may indicate heparin-
induced thrombocytopenia (HIT), a serious immune-mediated
complication that increases the risk of thrombosis despite
thrombocytopenia. Immediate discontinuation of heparin and provider
notification are required.
3. A client with chronic kidney disease has a serum potassium level
of 6.8 mEq/L. Which intervention should the nurse anticipate first?
A. Restrict sodium intake
B. Administer intravenous calcium gluconate
,C. Encourage oral fluids
D. Administer a stool softener
Answer: B. Administer intravenous calcium gluconate
Rationale: Severe hyperkalemia places the client at immediate risk for
fatal cardiac dysrhythmias. Intravenous calcium gluconate stabilizes
myocardial cell membranes, reducing the risk of lethal arrhythmias
while additional therapies lower the serum potassium level.
4. Which assessment finding is most characteristic of left-sided heart
failure?
A. Hepatomegaly
B. Ascites
C. Pulmonary crackles
D. Peripheral edema
Answer: C. Pulmonary crackles
Rationale: Left-sided heart failure results in pulmonary congestion
because blood backs up into the lungs. Crackles, dyspnea, orthopnea,
and pulmonary edema are hallmark findings. Right-sided heart failure
produces systemic venous congestion, including peripheral edema,
ascites, and hepatomegaly.
, 5. A nurse is monitoring a client after a thyroidectomy. Which finding
requires immediate action?
A. Mild incisional pain
B. Hoarseness
C. Tingling around the mouth
D. Temperature of 99°F (37.2°C)
Answer: C. Tingling around the mouth
Rationale: Perioral tingling suggests hypocalcemia caused by accidental
removal or injury to the parathyroid glands. Untreated hypocalcemia
can progress to tetany, laryngospasm, seizures, and cardiac
complications.
6. A client with sepsis develops hypotension despite fluid
resuscitation. Which medication should the nurse anticipate?
A. Furosemide
B. Norepinephrine
C. Digoxin
D. Metoprolol
Answer: B. Norepinephrine
Needs Exam 2 Questions And Correct Answers
(Verified Answers) Plus Rationale 2027 Q&A|
Instant Download Pdf
1. A nurse is caring for a client admitted with acute decompensated
heart failure. Which assessment finding requires immediate
intervention?
A. Bilateral ankle edema
B. Weight gain of 2 lb (0.9 kg) in 24 hours
C. Crackles throughout both lung fields and oxygen saturation of 84%
D. Jugular venous distention
Answer: C. Crackles throughout both lung fields and oxygen saturation
of 84%
Rationale: Diffuse crackles accompanied by severe hypoxemia indicate
acute pulmonary edema and impaired gas exchange, which is life-
threatening. Airway and oxygenation always take priority according to
the ABCs. Peripheral edema, weight gain, and jugular venous distention
,indicate worsening heart failure but are not as immediately life-
threatening as severe respiratory compromise.
2. Which laboratory value should concern the nurse most for a client
receiving intravenous heparin?
A. Platelet count of 45,000/mm³
B. Sodium of 138 mEq/L
C. Potassium of 4.0 mEq/L
D. Hemoglobin of 13 g/dL
Answer: A. Platelet count of 45,000/mm³
Rationale: A significantly decreased platelet count may indicate heparin-
induced thrombocytopenia (HIT), a serious immune-mediated
complication that increases the risk of thrombosis despite
thrombocytopenia. Immediate discontinuation of heparin and provider
notification are required.
3. A client with chronic kidney disease has a serum potassium level
of 6.8 mEq/L. Which intervention should the nurse anticipate first?
A. Restrict sodium intake
B. Administer intravenous calcium gluconate
,C. Encourage oral fluids
D. Administer a stool softener
Answer: B. Administer intravenous calcium gluconate
Rationale: Severe hyperkalemia places the client at immediate risk for
fatal cardiac dysrhythmias. Intravenous calcium gluconate stabilizes
myocardial cell membranes, reducing the risk of lethal arrhythmias
while additional therapies lower the serum potassium level.
4. Which assessment finding is most characteristic of left-sided heart
failure?
A. Hepatomegaly
B. Ascites
C. Pulmonary crackles
D. Peripheral edema
Answer: C. Pulmonary crackles
Rationale: Left-sided heart failure results in pulmonary congestion
because blood backs up into the lungs. Crackles, dyspnea, orthopnea,
and pulmonary edema are hallmark findings. Right-sided heart failure
produces systemic venous congestion, including peripheral edema,
ascites, and hepatomegaly.
, 5. A nurse is monitoring a client after a thyroidectomy. Which finding
requires immediate action?
A. Mild incisional pain
B. Hoarseness
C. Tingling around the mouth
D. Temperature of 99°F (37.2°C)
Answer: C. Tingling around the mouth
Rationale: Perioral tingling suggests hypocalcemia caused by accidental
removal or injury to the parathyroid glands. Untreated hypocalcemia
can progress to tetany, laryngospasm, seizures, and cardiac
complications.
6. A client with sepsis develops hypotension despite fluid
resuscitation. Which medication should the nurse anticipate?
A. Furosemide
B. Norepinephrine
C. Digoxin
D. Metoprolol
Answer: B. Norepinephrine
