NURS 4581 Nursing of Adults with Complex
Needs Exam 1 Questions And Correct
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is assessing a client admitted with septic shock. Which
assessment finding requires immediate intervention?
A. Temperature of 38.3°C (101°F)
B. Heart rate of 112 beats/min
C. Mean arterial pressure (MAP) of 58 mm Hg
D. Respiratory rate of 24 breaths/min
Answer: C. Mean arterial pressure (MAP) of 58 mm Hg
Rationale: A MAP below 65 mm Hg indicates inadequate tissue
perfusion and places the client at risk for multiple organ dysfunction.
Although fever, tachycardia, and tachypnea are expected manifestations
of sepsis, hypotension is the priority because it directly threatens organ
perfusion. Prompt fluid resuscitation and vasopressor therapy may be
necessary.
, 2. Which laboratory value best indicates adequate anticoagulation in
a client receiving intravenous unfractionated heparin?
A. INR of 2.5
B. Platelet count of 180,000/mm³
C. Activated partial thromboplastin time (aPTT) of 70 seconds
D. Hemoglobin of 14 g/dL
Answer: C. Activated partial thromboplastin time (aPTT) of 70 seconds
Rationale: Therapeutic intravenous heparin therapy is monitored using
the aPTT, which is generally maintained at approximately 1.5 to 2.5
times the normal value. INR is used to monitor warfarin therapy.
Platelet count and hemoglobin provide additional safety information
but do not measure therapeutic anticoagulation.
3. A client develops sudden shortness of breath after hip
replacement surgery. Which complication should the nurse
suspect first?
A. Atelectasis
B. Pulmonary embolism
,C. Pneumonia
D. Pleural effusion
Answer: B. Pulmonary embolism
Rationale: Orthopedic surgery, particularly involving the lower
extremities, significantly increases the risk for deep vein thrombosis and
pulmonary embolism. Sudden dyspnea, chest pain, tachycardia, and
hypoxemia are classic findings requiring immediate medical evaluation.
4. Which intervention has the highest priority for a client
experiencing acute respiratory distress syndrome (ARDS)?
A. Restrict oral fluids
B. Administer high-concentration oxygen as prescribed
C. Encourage coughing every 4 hours
D. Place the client in Trendelenburg position
Answer: B. Administer high-concentration oxygen as prescribed
Rationale: ARDS causes severe impairment in gas exchange. Immediate
oxygen therapy and ventilatory support are essential to improve
oxygenation and prevent tissue hypoxia. Trendelenburg positioning is
not recommended and may worsen respiratory status.
, 5. Which assessment finding is most consistent with left-sided heart
failure?
A. Peripheral edema
B. Jugular venous distention
C. Crackles in the lungs
D. Hepatomegaly
Answer: C. Crackles in the lungs
Rationale: Left-sided heart failure leads to pulmonary congestion
because blood backs up into the pulmonary circulation. Crackles,
dyspnea, orthopnea, and pulmonary edema are characteristic findings.
Peripheral edema and hepatomegaly are more commonly associated
with right-sided heart failure.
6. Which electrolyte imbalance places a client at the greatest risk for
life-threatening cardiac dysrhythmias?
A. Sodium 135 mEq/L
B. Potassium 2.8 mEq/L
C. Chloride 101 mEq/L
Needs Exam 1 Questions And Correct
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is assessing a client admitted with septic shock. Which
assessment finding requires immediate intervention?
A. Temperature of 38.3°C (101°F)
B. Heart rate of 112 beats/min
C. Mean arterial pressure (MAP) of 58 mm Hg
D. Respiratory rate of 24 breaths/min
Answer: C. Mean arterial pressure (MAP) of 58 mm Hg
Rationale: A MAP below 65 mm Hg indicates inadequate tissue
perfusion and places the client at risk for multiple organ dysfunction.
Although fever, tachycardia, and tachypnea are expected manifestations
of sepsis, hypotension is the priority because it directly threatens organ
perfusion. Prompt fluid resuscitation and vasopressor therapy may be
necessary.
, 2. Which laboratory value best indicates adequate anticoagulation in
a client receiving intravenous unfractionated heparin?
A. INR of 2.5
B. Platelet count of 180,000/mm³
C. Activated partial thromboplastin time (aPTT) of 70 seconds
D. Hemoglobin of 14 g/dL
Answer: C. Activated partial thromboplastin time (aPTT) of 70 seconds
Rationale: Therapeutic intravenous heparin therapy is monitored using
the aPTT, which is generally maintained at approximately 1.5 to 2.5
times the normal value. INR is used to monitor warfarin therapy.
Platelet count and hemoglobin provide additional safety information
but do not measure therapeutic anticoagulation.
3. A client develops sudden shortness of breath after hip
replacement surgery. Which complication should the nurse
suspect first?
A. Atelectasis
B. Pulmonary embolism
,C. Pneumonia
D. Pleural effusion
Answer: B. Pulmonary embolism
Rationale: Orthopedic surgery, particularly involving the lower
extremities, significantly increases the risk for deep vein thrombosis and
pulmonary embolism. Sudden dyspnea, chest pain, tachycardia, and
hypoxemia are classic findings requiring immediate medical evaluation.
4. Which intervention has the highest priority for a client
experiencing acute respiratory distress syndrome (ARDS)?
A. Restrict oral fluids
B. Administer high-concentration oxygen as prescribed
C. Encourage coughing every 4 hours
D. Place the client in Trendelenburg position
Answer: B. Administer high-concentration oxygen as prescribed
Rationale: ARDS causes severe impairment in gas exchange. Immediate
oxygen therapy and ventilatory support are essential to improve
oxygenation and prevent tissue hypoxia. Trendelenburg positioning is
not recommended and may worsen respiratory status.
, 5. Which assessment finding is most consistent with left-sided heart
failure?
A. Peripheral edema
B. Jugular venous distention
C. Crackles in the lungs
D. Hepatomegaly
Answer: C. Crackles in the lungs
Rationale: Left-sided heart failure leads to pulmonary congestion
because blood backs up into the pulmonary circulation. Crackles,
dyspnea, orthopnea, and pulmonary edema are characteristic findings.
Peripheral edema and hepatomegaly are more commonly associated
with right-sided heart failure.
6. Which electrolyte imbalance places a client at the greatest risk for
life-threatening cardiac dysrhythmias?
A. Sodium 135 mEq/L
B. Potassium 2.8 mEq/L
C. Chloride 101 mEq/L
