NUR 211 Exam 4 – Comprehensive Questions and
Answers with Detailed Rationales
1. A nurse is assessing a client who reports shortness of breath. Which
assessment finding requires the most immediate intervention?
A. Respiratory rate of 22/min
B. Oxygen saturation of 86%
C. Mild productive cough
D. Temperature of 37.4°C (99.3°F)
Answer: B. Oxygen saturation of 86%
Rationale: An oxygen saturation of 86% indicates significant hypoxemia
and requires prompt assessment and intervention. The other findings
are less immediately concerning.
2. Which assessment finding is most consistent with hypovolemia?
A. Bounding pulse
B. Hypertension
C. Tachycardia with weak peripheral pulses
D. Jugular venous distention
Answer: C. Tachycardia with weak peripheral pulses
Rationale: Reduced circulating volume commonly produces
compensatory tachycardia and weak peripheral pulses. Bounding pulses
and JVD are more consistent with fluid excess.
3. A client with heart failure suddenly develops severe dyspnea and
pink, frothy sputum. What complication should the nurse suspect?
A. Pulmonary edema
B. Pneumothorax
C. Pleural effusion
D. Pulmonary embolism
,Answer: A. Pulmonary edema
Rationale: Acute pulmonary edema can cause severe respiratory
distress, crackles, hypoxemia, and pink, frothy sputum because fluid
has entered the alveoli.
4. Which finding is characteristic of left-sided heart failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
Rationale: Left ventricular failure causes blood to back up into the
pulmonary circulation, producing pulmonary congestion and crackles.
5. Which finding is most characteristic of right-sided heart failure?
A. Pulmonary crackles
B. Peripheral edema
C. Hemoptysis
D. Orthopnea only
Answer: B. Peripheral edema
Rationale: Right-sided heart failure causes systemic venous congestion,
commonly resulting in dependent edema, JVD, hepatomegaly, and
ascites.
6. A client taking furosemide should be monitored closely for which
electrolyte abnormality?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypermagnesemia
,Answer: C. Hypokalemia
Rationale: Furosemide is a loop diuretic that increases urinary
potassium loss. Potassium monitoring is important because severe
hypokalemia can cause dysrhythmias.
7. Which laboratory value should cause the nurse to question
administration of potassium chloride?
A. Potassium 2.9 mEq/L
B. Potassium 3.2 mEq/L
C. Potassium 4.1 mEq/L
D. Potassium 6.1 mEq/L
Answer: D. Potassium 6.1 mEq/L
Rationale: A potassium of 6.1 mEq/L represents significant
hyperkalemia. Additional potassium could worsen the condition and
precipitate dangerous cardiac dysrhythmias.
8. Which ECG change is commonly associated with hyperkalemia?
A. Peaked T waves
B. U waves
C. Prolonged QT interval only
D. ST elevation in all leads
Answer: A. Peaked T waves
Rationale: Early hyperkalemia classically produces tall, peaked T waves.
Progressive hyperkalemia can cause widening of the QRS and
potentially fatal dysrhythmias.
9. A client receiving digoxin reports nausea and seeing yellow halos.
What should the nurse suspect?
A. Therapeutic response
B. Digoxin toxicity
, C. Hypocalcemia
D. Dehydration
Answer: B. Digoxin toxicity
Rationale: Gastrointestinal symptoms and visual disturbances such as
yellow or blurred vision are classic manifestations of digoxin toxicity.
Bradycardia and dysrhythmias may also occur.
10. Before administering digoxin, which assessment is most important?
A. Respiratory depth
B. Apical pulse
C. Bowel sounds
D. Skin temperature
Answer: B. Apical pulse
Rationale: Digoxin slows cardiac conduction. The nurse should assess
the apical pulse before administration and follow the prescribed
parameters for withholding the medication.
11. A client with angina is prescribed sublingual nitroglycerin. What
instruction is most appropriate?
A. Swallow the tablet with water
B. Take it only after meals
C. Place the tablet under the tongue
D. Crush it and mix it with food
Answer: C. Place the tablet under the tongue
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid
absorption through the oral mucosa.
12. Which adverse effect is common with nitroglycerin?
A. Severe constipation
B. Headache
Answers with Detailed Rationales
1. A nurse is assessing a client who reports shortness of breath. Which
assessment finding requires the most immediate intervention?
A. Respiratory rate of 22/min
B. Oxygen saturation of 86%
C. Mild productive cough
D. Temperature of 37.4°C (99.3°F)
Answer: B. Oxygen saturation of 86%
Rationale: An oxygen saturation of 86% indicates significant hypoxemia
and requires prompt assessment and intervention. The other findings
are less immediately concerning.
2. Which assessment finding is most consistent with hypovolemia?
A. Bounding pulse
B. Hypertension
C. Tachycardia with weak peripheral pulses
D. Jugular venous distention
Answer: C. Tachycardia with weak peripheral pulses
Rationale: Reduced circulating volume commonly produces
compensatory tachycardia and weak peripheral pulses. Bounding pulses
and JVD are more consistent with fluid excess.
3. A client with heart failure suddenly develops severe dyspnea and
pink, frothy sputum. What complication should the nurse suspect?
A. Pulmonary edema
B. Pneumothorax
C. Pleural effusion
D. Pulmonary embolism
,Answer: A. Pulmonary edema
Rationale: Acute pulmonary edema can cause severe respiratory
distress, crackles, hypoxemia, and pink, frothy sputum because fluid
has entered the alveoli.
4. Which finding is characteristic of left-sided heart failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
Rationale: Left ventricular failure causes blood to back up into the
pulmonary circulation, producing pulmonary congestion and crackles.
5. Which finding is most characteristic of right-sided heart failure?
A. Pulmonary crackles
B. Peripheral edema
C. Hemoptysis
D. Orthopnea only
Answer: B. Peripheral edema
Rationale: Right-sided heart failure causes systemic venous congestion,
commonly resulting in dependent edema, JVD, hepatomegaly, and
ascites.
6. A client taking furosemide should be monitored closely for which
electrolyte abnormality?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypermagnesemia
,Answer: C. Hypokalemia
Rationale: Furosemide is a loop diuretic that increases urinary
potassium loss. Potassium monitoring is important because severe
hypokalemia can cause dysrhythmias.
7. Which laboratory value should cause the nurse to question
administration of potassium chloride?
A. Potassium 2.9 mEq/L
B. Potassium 3.2 mEq/L
C. Potassium 4.1 mEq/L
D. Potassium 6.1 mEq/L
Answer: D. Potassium 6.1 mEq/L
Rationale: A potassium of 6.1 mEq/L represents significant
hyperkalemia. Additional potassium could worsen the condition and
precipitate dangerous cardiac dysrhythmias.
8. Which ECG change is commonly associated with hyperkalemia?
A. Peaked T waves
B. U waves
C. Prolonged QT interval only
D. ST elevation in all leads
Answer: A. Peaked T waves
Rationale: Early hyperkalemia classically produces tall, peaked T waves.
Progressive hyperkalemia can cause widening of the QRS and
potentially fatal dysrhythmias.
9. A client receiving digoxin reports nausea and seeing yellow halos.
What should the nurse suspect?
A. Therapeutic response
B. Digoxin toxicity
, C. Hypocalcemia
D. Dehydration
Answer: B. Digoxin toxicity
Rationale: Gastrointestinal symptoms and visual disturbances such as
yellow or blurred vision are classic manifestations of digoxin toxicity.
Bradycardia and dysrhythmias may also occur.
10. Before administering digoxin, which assessment is most important?
A. Respiratory depth
B. Apical pulse
C. Bowel sounds
D. Skin temperature
Answer: B. Apical pulse
Rationale: Digoxin slows cardiac conduction. The nurse should assess
the apical pulse before administration and follow the prescribed
parameters for withholding the medication.
11. A client with angina is prescribed sublingual nitroglycerin. What
instruction is most appropriate?
A. Swallow the tablet with water
B. Take it only after meals
C. Place the tablet under the tongue
D. Crush it and mix it with food
Answer: C. Place the tablet under the tongue
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid
absorption through the oral mucosa.
12. Which adverse effect is common with nitroglycerin?
A. Severe constipation
B. Headache
