NUR 253 Exam 2 | UPDATED
Questions with 100% Correct
Answers
Course
NUR 253
1. A nurse is caring for a client with heart failure. Which assessment finding indicates
worsening left-sided heart failure?
A. Jugular venous distention
B. Bilateral crackles in the lungs
C. Peripheral edema
D. Ascites
Answer: B. Bilateral crackles in the lungs
Solution:
Left-sided heart failure causes blood to back up into the pulmonary circulation, leading to
pulmonary congestion and crackles. Peripheral edema and jugular venous distention are more
commonly associated with right-sided heart failure.
2. A client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of
89% on room air. What is the nurse's priority action?
A. Apply high-flow oxygen at 15 L/min.
B. Administer low-flow oxygen as prescribed.
C. Encourage vigorous coughing.
D. Place the client flat in bed.
Answer: B. Administer low-flow oxygen as prescribed.
Solution:
Clients with COPD often require controlled oxygen therapy to improve oxygenation while
minimizing the risk of worsening hypercapnia. Oxygen should be administered according to the
prescribed target saturation.
,3. Which laboratory value is most concerning for a client receiving furosemide?
A. Potassium 2.9 mEq/L
B. Sodium 138 mEq/L
C. Chloride 102 mEq/L
D. Calcium 9.1 mg/dL
Answer: A. Potassium 2.9 mEq/L
Solution:
Loop diuretics commonly cause hypokalemia, which increases the risk of dysrhythmias and
muscle weakness.
4. Which assessment finding is most characteristic of hypoglycemia?
A. Warm, dry skin
B. Tremors and diaphoresis
C. Fruity breath odor
D. Kussmaul respirations
Answer: B. Tremors and diaphoresis
Solution:
Hypoglycemia activates the sympathetic nervous system, producing sweating, tremors,
tachycardia, and anxiety.
5. A client develops sudden chest pain and shortness of breath after surgery. What
complication should the nurse suspect first?
A. Pneumonia
B. Pulmonary embolism
C. Pleural effusion
D. Atelectasis
Answer: B. Pulmonary embolism
,Solution:
Acute dyspnea, chest pain, tachycardia, and hypoxemia after surgery are classic signs of
pulmonary embolism.
6. Which electrolyte imbalance is most commonly associated with peaked T waves on an ECG?
A. Hypokalemia
B. Hyperkalemia
C. Hypocalcemia
D. Hyponatremia
Answer: B. Hyperkalemia
Solution:
Hyperkalemia produces tall, peaked T waves and can progress to life-threatening cardiac
conduction abnormalities.
7. Which intervention has the highest priority for a client experiencing an acute asthma
attack?
A. Encourage fluid intake.
B. Administer a rapid-acting bronchodilator.
C. Restrict activity for 24 hours.
D. Begin chest physiotherapy.
Answer: B. Administer a rapid-acting bronchodilator.
Solution:
Rapid bronchodilation is the priority to relieve airway obstruction during an acute asthma
exacerbation.
8. Which assessment finding is expected in dehydration?
A. Bounding pulse
B. Dry mucous membranes
, C. Pulmonary crackles
D. Peripheral edema
Answer: B. Dry mucous membranes
Solution:
Dehydration commonly causes dry mucous membranes, decreased skin turgor, tachycardia, and
concentrated urine.
9. Which client is at greatest risk for developing pressure injuries?
A. Ambulatory client with hypertension
B. Immobile client with poor nutrition
C. Client with seasonal allergies
D. Client recovering from a minor laceration
Answer: B. Immobile client with poor nutrition
Solution:
Immobility and malnutrition significantly increase the risk of impaired skin integrity.
10. Which finding indicates that morphine is effective for a client with acute pulmonary
edema?
A. Increased anxiety
B. Decreased dyspnea
C. Increased crackles
D. Oxygen saturation decreases
Answer: B. Decreased dyspnea
Solution:
Morphine may reduce anxiety and the sensation of breathlessness while decreasing preload in
selected patients.
11. Which laboratory test best evaluates long-term glucose control?
Questions with 100% Correct
Answers
Course
NUR 253
1. A nurse is caring for a client with heart failure. Which assessment finding indicates
worsening left-sided heart failure?
A. Jugular venous distention
B. Bilateral crackles in the lungs
C. Peripheral edema
D. Ascites
Answer: B. Bilateral crackles in the lungs
Solution:
Left-sided heart failure causes blood to back up into the pulmonary circulation, leading to
pulmonary congestion and crackles. Peripheral edema and jugular venous distention are more
commonly associated with right-sided heart failure.
2. A client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of
89% on room air. What is the nurse's priority action?
A. Apply high-flow oxygen at 15 L/min.
B. Administer low-flow oxygen as prescribed.
C. Encourage vigorous coughing.
D. Place the client flat in bed.
Answer: B. Administer low-flow oxygen as prescribed.
Solution:
Clients with COPD often require controlled oxygen therapy to improve oxygenation while
minimizing the risk of worsening hypercapnia. Oxygen should be administered according to the
prescribed target saturation.
,3. Which laboratory value is most concerning for a client receiving furosemide?
A. Potassium 2.9 mEq/L
B. Sodium 138 mEq/L
C. Chloride 102 mEq/L
D. Calcium 9.1 mg/dL
Answer: A. Potassium 2.9 mEq/L
Solution:
Loop diuretics commonly cause hypokalemia, which increases the risk of dysrhythmias and
muscle weakness.
4. Which assessment finding is most characteristic of hypoglycemia?
A. Warm, dry skin
B. Tremors and diaphoresis
C. Fruity breath odor
D. Kussmaul respirations
Answer: B. Tremors and diaphoresis
Solution:
Hypoglycemia activates the sympathetic nervous system, producing sweating, tremors,
tachycardia, and anxiety.
5. A client develops sudden chest pain and shortness of breath after surgery. What
complication should the nurse suspect first?
A. Pneumonia
B. Pulmonary embolism
C. Pleural effusion
D. Atelectasis
Answer: B. Pulmonary embolism
,Solution:
Acute dyspnea, chest pain, tachycardia, and hypoxemia after surgery are classic signs of
pulmonary embolism.
6. Which electrolyte imbalance is most commonly associated with peaked T waves on an ECG?
A. Hypokalemia
B. Hyperkalemia
C. Hypocalcemia
D. Hyponatremia
Answer: B. Hyperkalemia
Solution:
Hyperkalemia produces tall, peaked T waves and can progress to life-threatening cardiac
conduction abnormalities.
7. Which intervention has the highest priority for a client experiencing an acute asthma
attack?
A. Encourage fluid intake.
B. Administer a rapid-acting bronchodilator.
C. Restrict activity for 24 hours.
D. Begin chest physiotherapy.
Answer: B. Administer a rapid-acting bronchodilator.
Solution:
Rapid bronchodilation is the priority to relieve airway obstruction during an acute asthma
exacerbation.
8. Which assessment finding is expected in dehydration?
A. Bounding pulse
B. Dry mucous membranes
, C. Pulmonary crackles
D. Peripheral edema
Answer: B. Dry mucous membranes
Solution:
Dehydration commonly causes dry mucous membranes, decreased skin turgor, tachycardia, and
concentrated urine.
9. Which client is at greatest risk for developing pressure injuries?
A. Ambulatory client with hypertension
B. Immobile client with poor nutrition
C. Client with seasonal allergies
D. Client recovering from a minor laceration
Answer: B. Immobile client with poor nutrition
Solution:
Immobility and malnutrition significantly increase the risk of impaired skin integrity.
10. Which finding indicates that morphine is effective for a client with acute pulmonary
edema?
A. Increased anxiety
B. Decreased dyspnea
C. Increased crackles
D. Oxygen saturation decreases
Answer: B. Decreased dyspnea
Solution:
Morphine may reduce anxiety and the sensation of breathlessness while decreasing preload in
selected patients.
11. Which laboratory test best evaluates long-term glucose control?
