Nurs 480 Exam 2 Newest Actual Exam Preparation With Complete Questions
And Correct Answers With Rationales | Already Graded A+||Brand New
Version!!
Question 1
Which nursing intervention for a patient who had an open repair of an abdominal aortic
aneurysm (AAA) 2 days previously is appropriate for the nurse to delegate to unlicensed
assistive personnel (UAP)?
A) Monitor the quality and presence of the pedal pulses to check for occlusion.
B) Teach the patient the signs and symptoms of a possible wound infection.
C) Check the lower extremities for strength, movement, and neurological sensation.
D) Help the patient to use a pillow to splint the incision while coughing and deep breathing.
E) Evaluate the patient's renal function by monitoring hourly urine output.
Correct Answer: D) Help the patient to use a pillow to splint while coughing
Rationale: Assisting a stable patient with splinting an incision during coughing and deep
breathing is a standard task that falls within the scope of practice for a UAP. This task is
repetitive and does not require clinical judgment or nursing assessment. Monitoring pulses
(A), teaching (B), checking neurological status (C), and evaluating organ function (E) all
require the specialized assessment skills and clinical knowledge of a licensed Registered
Nurse.
Question 2
A nurse is unable to read the telemetry monitor at the central nursing station. Which intervention
should the nurse implement first?
A) Go to the client's room and perform a physical assessment of the client.
B) Instruct the designated telemetry nurse to check the monitor again.
C) Contact the client through the room's call system to ask how they are feeling.
D) Request the nursing assistant to take the crash cart to the client's room immediately.
E) Call a "Code Blue" based on the assumption of a lethal rhythm.
Correct Answer: A) Go the the clients room and assess the client
Rationale: In the event of a telemetry failure or an unreadable strip, the primary nurse's
priority is to "treat the patient, not the monitor." The nurse must physically assess the
client to determine if they are in distress, if the leads have simply become detached, or if the
, 2
equipment is malfunctioning. Communicating via the call system (C) is insufficient for a
cardiac patient, and calling for a crash cart (D) or code (E) is premature without a physical
assessment confirming an emergency.
Question 3
A patient with chest pain that is unrelieved by nitroglycerin is admitted to the coronary care unit.
While the patient has continuous ECG monitoring, which finding would most concern the nurse?
A) Occasional Premature Ventricular Contractions (PVCs).
B) A minor change in the amplitude of the QRS complex.
C) ST-segment elevation in two or more contiguous leads.
D) A PR interval of 0.18 seconds.
E) A heart rate of 92 beats per minute.
Correct Answer: C) ST segment elevation
Rationale: ST-segment elevation is an indicator of acute myocardial injury and suggests a
complete occlusion of a coronary artery (STEMI). This is a medical emergency requiring
immediate reperfusion therapy. Occasional PVCs (A) are common, a PR interval of 0.18
(D) is within the normal range (0.12–0.20), and a HR of 92 (E) is a normal sinus rhythm. ST
elevation represents active tissue death and is the highest priority finding.
Question 4
Which assessment data would warrant immediate intervention in a client diagnosed with arterial
occlusive disease?
A) The client has 2+ (normal) pedal pulses.
B) The client is able to move their toes and wiggle their feet.
C) The client reports new-onset numbness and tingling in the affected limb.
D) The client's feet appear red (rubor) when in a dependent position.
E) The client has a history of high cholesterol and smoking.
Correct Answer: C) The client has numbness and tingling
Rationale: Paresthesia (numbness and tingling) is one of the "6 Ps" of acute arterial
occlusion and indicates that the nerves are being deprived of oxygenated blood. This
finding suggests the condition is worsening and the limb may be at risk for ischemia.
, 3
Normal pulses (A) and movement (B) are positive signs. Redness when standing (D) is
common in chronic PAD (dependent rubor) but does not signify the same acute emergency
as new-onset neurological deficits.
Question 5
During care of a patient following a femoral-popliteal bypass graft surgery, the nurse should
immediately notify the healthcare provider if the patient experiences:
A) Low-grade fever and slight redness at the incision site.
B) 2+ edema of the extremity and mild pain at the incision site.
C) A loss of palpable pulses and numbness/tingling of the feet.
D) An increasing ankle-brachial index (ABI) and serous drainage.
E) A heart rate of 88 and clear lung sounds.
Correct Answer: C) A loss of palpable pulses and numbness and tingling of the feet
Rationale: A sudden loss of previously palpable pulses combined with paresthesia
(numbness/tingling) strongly suggests an acute graft occlusion or a blood clot within the
new bypass. This is a surgical emergency. Fever (A) and mild pain/edema (B) are expected
post-operative findings, and an increasing ABI (D) actually indicates improved perfusion.
The loss of pulses indicates the surgery has failed or been compromised.
Question 6
The nurse is caring for clients on a telemetry floor. Which nursing task would be most
appropriate to delegate to an unlicensed assistive personnel (UAP)?
A) Teach the client how to perform a glucometer check for diabetes management.
B) Assist in feeding a stable client diagnosed with congestive heart failure.
C) Check the total cholesterol and LDL levels for a client with atherosclerosis.
D) Assist the nurse in checking and identifying a unit of blood at the bedside.
E) Adjust the parameters on the patient's telemetry alarm system.
Correct Answer: B) Assist feeding the client diagnosed with congestive heart failure
Rationale: UAPs are trained to assist with Activities of Daily Living (ADLs) such as feeding,
grooming, and mobility for stable patients. Teaching (A), interpreting lab values (C), and
participating in the two-person verification of blood products (D) are high-responsibility
, 4
tasks reserved for licensed nurses. Adjusting telemetry settings (E) requires clinical
knowledge of heart rhythms.
Question 7
Ordered: IV Nesiritide, 2 mcg/kg STAT for exacerbation of Heart Failure.
Have: 40 mcg Nesiritide per 3 mL.
Patient's weight: 176 lbs (80 kg).
How many mLs will you give to your patient for this STAT dose?
A) 6 mL
B) 8 mL
C) 10 mL
D) 12 mL
E) 15 mL
Correct Answer: D) 12
Rationale: First, calculate the total dose required: 80 kg × 2 mcg/kg = 160 mcg. Next, use the
available concentration to find the volume: (160 mcg ÷ 40 mcg) × 3 mL = 4 × 3 mL = 12 mL.
The nurse should administer 12 mL of the medication.
Question 8
The client diagnosed with arterial occlusive disease is one day postoperative right femoral-
popliteal bypass. Which intervention should the nurse implement?
A) Keep the right leg in a dependent position to promote gravity flow.
B) Apply sequential compression devices (SCDs) to the lower extremities.
C) Monitor the client's pedal pulses every 2 to 4 hours.
D) Assess the client's surgical leg dressing once every 24 hours.
E) Encourage the patient to cross their legs to reduce stretching the graft.
Correct Answer: C) Monitor the clients pedal pulses every 2-4 hours
Rationale: Post-operative care for a bypass graft requires frequent neurovascular checks to
ensure the graft remains patent. Pedal pulses should be checked every 2–4 hours (or more
frequently per hospital protocol) to detect early signs of occlusion. The leg should not be
dependent (A) to avoid edema, and SCDs (B) are often avoided on the surgical leg initially
And Correct Answers With Rationales | Already Graded A+||Brand New
Version!!
Question 1
Which nursing intervention for a patient who had an open repair of an abdominal aortic
aneurysm (AAA) 2 days previously is appropriate for the nurse to delegate to unlicensed
assistive personnel (UAP)?
A) Monitor the quality and presence of the pedal pulses to check for occlusion.
B) Teach the patient the signs and symptoms of a possible wound infection.
C) Check the lower extremities for strength, movement, and neurological sensation.
D) Help the patient to use a pillow to splint the incision while coughing and deep breathing.
E) Evaluate the patient's renal function by monitoring hourly urine output.
Correct Answer: D) Help the patient to use a pillow to splint while coughing
Rationale: Assisting a stable patient with splinting an incision during coughing and deep
breathing is a standard task that falls within the scope of practice for a UAP. This task is
repetitive and does not require clinical judgment or nursing assessment. Monitoring pulses
(A), teaching (B), checking neurological status (C), and evaluating organ function (E) all
require the specialized assessment skills and clinical knowledge of a licensed Registered
Nurse.
Question 2
A nurse is unable to read the telemetry monitor at the central nursing station. Which intervention
should the nurse implement first?
A) Go to the client's room and perform a physical assessment of the client.
B) Instruct the designated telemetry nurse to check the monitor again.
C) Contact the client through the room's call system to ask how they are feeling.
D) Request the nursing assistant to take the crash cart to the client's room immediately.
E) Call a "Code Blue" based on the assumption of a lethal rhythm.
Correct Answer: A) Go the the clients room and assess the client
Rationale: In the event of a telemetry failure or an unreadable strip, the primary nurse's
priority is to "treat the patient, not the monitor." The nurse must physically assess the
client to determine if they are in distress, if the leads have simply become detached, or if the
, 2
equipment is malfunctioning. Communicating via the call system (C) is insufficient for a
cardiac patient, and calling for a crash cart (D) or code (E) is premature without a physical
assessment confirming an emergency.
Question 3
A patient with chest pain that is unrelieved by nitroglycerin is admitted to the coronary care unit.
While the patient has continuous ECG monitoring, which finding would most concern the nurse?
A) Occasional Premature Ventricular Contractions (PVCs).
B) A minor change in the amplitude of the QRS complex.
C) ST-segment elevation in two or more contiguous leads.
D) A PR interval of 0.18 seconds.
E) A heart rate of 92 beats per minute.
Correct Answer: C) ST segment elevation
Rationale: ST-segment elevation is an indicator of acute myocardial injury and suggests a
complete occlusion of a coronary artery (STEMI). This is a medical emergency requiring
immediate reperfusion therapy. Occasional PVCs (A) are common, a PR interval of 0.18
(D) is within the normal range (0.12–0.20), and a HR of 92 (E) is a normal sinus rhythm. ST
elevation represents active tissue death and is the highest priority finding.
Question 4
Which assessment data would warrant immediate intervention in a client diagnosed with arterial
occlusive disease?
A) The client has 2+ (normal) pedal pulses.
B) The client is able to move their toes and wiggle their feet.
C) The client reports new-onset numbness and tingling in the affected limb.
D) The client's feet appear red (rubor) when in a dependent position.
E) The client has a history of high cholesterol and smoking.
Correct Answer: C) The client has numbness and tingling
Rationale: Paresthesia (numbness and tingling) is one of the "6 Ps" of acute arterial
occlusion and indicates that the nerves are being deprived of oxygenated blood. This
finding suggests the condition is worsening and the limb may be at risk for ischemia.
, 3
Normal pulses (A) and movement (B) are positive signs. Redness when standing (D) is
common in chronic PAD (dependent rubor) but does not signify the same acute emergency
as new-onset neurological deficits.
Question 5
During care of a patient following a femoral-popliteal bypass graft surgery, the nurse should
immediately notify the healthcare provider if the patient experiences:
A) Low-grade fever and slight redness at the incision site.
B) 2+ edema of the extremity and mild pain at the incision site.
C) A loss of palpable pulses and numbness/tingling of the feet.
D) An increasing ankle-brachial index (ABI) and serous drainage.
E) A heart rate of 88 and clear lung sounds.
Correct Answer: C) A loss of palpable pulses and numbness and tingling of the feet
Rationale: A sudden loss of previously palpable pulses combined with paresthesia
(numbness/tingling) strongly suggests an acute graft occlusion or a blood clot within the
new bypass. This is a surgical emergency. Fever (A) and mild pain/edema (B) are expected
post-operative findings, and an increasing ABI (D) actually indicates improved perfusion.
The loss of pulses indicates the surgery has failed or been compromised.
Question 6
The nurse is caring for clients on a telemetry floor. Which nursing task would be most
appropriate to delegate to an unlicensed assistive personnel (UAP)?
A) Teach the client how to perform a glucometer check for diabetes management.
B) Assist in feeding a stable client diagnosed with congestive heart failure.
C) Check the total cholesterol and LDL levels for a client with atherosclerosis.
D) Assist the nurse in checking and identifying a unit of blood at the bedside.
E) Adjust the parameters on the patient's telemetry alarm system.
Correct Answer: B) Assist feeding the client diagnosed with congestive heart failure
Rationale: UAPs are trained to assist with Activities of Daily Living (ADLs) such as feeding,
grooming, and mobility for stable patients. Teaching (A), interpreting lab values (C), and
participating in the two-person verification of blood products (D) are high-responsibility
, 4
tasks reserved for licensed nurses. Adjusting telemetry settings (E) requires clinical
knowledge of heart rhythms.
Question 7
Ordered: IV Nesiritide, 2 mcg/kg STAT for exacerbation of Heart Failure.
Have: 40 mcg Nesiritide per 3 mL.
Patient's weight: 176 lbs (80 kg).
How many mLs will you give to your patient for this STAT dose?
A) 6 mL
B) 8 mL
C) 10 mL
D) 12 mL
E) 15 mL
Correct Answer: D) 12
Rationale: First, calculate the total dose required: 80 kg × 2 mcg/kg = 160 mcg. Next, use the
available concentration to find the volume: (160 mcg ÷ 40 mcg) × 3 mL = 4 × 3 mL = 12 mL.
The nurse should administer 12 mL of the medication.
Question 8
The client diagnosed with arterial occlusive disease is one day postoperative right femoral-
popliteal bypass. Which intervention should the nurse implement?
A) Keep the right leg in a dependent position to promote gravity flow.
B) Apply sequential compression devices (SCDs) to the lower extremities.
C) Monitor the client's pedal pulses every 2 to 4 hours.
D) Assess the client's surgical leg dressing once every 24 hours.
E) Encourage the patient to cross their legs to reduce stretching the graft.
Correct Answer: C) Monitor the clients pedal pulses every 2-4 hours
Rationale: Post-operative care for a bypass graft requires frequent neurovascular checks to
ensure the graft remains patent. Pedal pulses should be checked every 2–4 hours (or more
frequently per hospital protocol) to detect early signs of occlusion. The leg should not be
dependent (A) to avoid edema, and SCDs (B) are often avoided on the surgical leg initially
