NSG 434 Nursing Care – Exam 2 Practice Questions (2026/2027
Edition) Questions and Answers with Detailed Rationales
Question 1
A nurse is caring for a patient admitted with an ischemic stroke. Which
intervention should the nurse implement first?
A. Encourage oral fluids immediately
B. Assess the patient's swallowing ability before giving food, fluids, or
medications
C. Place the patient in a Trendelenburg position
D. Encourage independent ambulation immediately
Correct Answer: B. Assess the Patient's Swallowing Ability Before
Giving Food, Fluids, or Medications
Rationale:
Patients with acute stroke are at high risk for dysphagia and aspiration.
A swallowing assessment should be completed before administering
anything by mouth.
Question 2
A patient with chronic kidney disease has a serum potassium level of
6.5 mEq/L. Which electrocardiogram (ECG) finding should the nurse
anticipate?
A. Flattened T waves
B. Peaked T waves
C. Prolonged QT interval only
D. ST-segment elevation
,Correct Answer: B. Peaked T Waves
Rationale:
Hyperkalemia commonly produces tall, peaked T waves and can
progress to life-threatening dysrhythmias if untreated.
Question 3
A nurse is caring for a patient receiving a continuous heparin infusion.
Which laboratory value is most important to monitor?
A. Hemoglobin A1C
B. Activated partial thromboplastin time (aPTT)
C. Serum sodium
D. Total cholesterol
Correct Answer: B. Activated Partial Thromboplastin Time (aPTT)
Rationale:
The aPTT is monitored to ensure therapeutic anticoagulation and
reduce the risk of bleeding.
Question 4
A postoperative patient suddenly becomes restless, tachycardic, and
dyspneic. Which complication should the nurse suspect first?
A. Constipation
B. Pulmonary embolism
C. Urinary retention
D. Atelectasis only
,Correct Answer: B. Pulmonary Embolism
Rationale:
Sudden dyspnea, tachycardia, and restlessness following surgery are
classic signs of pulmonary embolism and require immediate evaluation.
Question 5
Which patient should the nurse assess first?
A. A patient reporting mild incisional pain
B. A patient with new-onset confusion and oxygen saturation of 85%
C. A patient requesting assistance with hygiene
D. A patient awaiting discharge
Correct Answer: B. A Patient With New-Onset Confusion and Oxygen
Saturation of 85%
Rationale:
Hypoxia and altered mental status indicate impaired oxygenation,
making this the highest-priority patient according to the ABC
framework.
Question 6
Which nursing intervention is most effective in preventing catheter-
associated urinary tract infections (CAUTIs)?
A. Irrigate the catheter daily
B. Remove the urinary catheter as soon as it is no longer clinically
necessary
, C. Disconnect the drainage tubing daily
D. Raise the drainage bag above bladder level
Correct Answer: B. Remove the Urinary Catheter as Soon as It Is No
Longer Clinically Necessary
Rationale:
Minimizing catheter duration is one of the most effective strategies for
preventing CAUTIs.
Question 7
A patient receiving blood transfusion develops fever, chills, and flank
pain. What should the nurse do first?
A. Continue the transfusion and reassess later
B. Stop the transfusion immediately
C. Slow the infusion rate
D. Administer acetaminophen before assessment
Correct Answer: B. Stop the Transfusion Immediately
Rationale:
These findings suggest an acute hemolytic transfusion reaction. The
transfusion should be stopped immediately while following institutional
protocols.
Question 8
Which assessment finding indicates improvement in a patient being
treated for heart failure?
Edition) Questions and Answers with Detailed Rationales
Question 1
A nurse is caring for a patient admitted with an ischemic stroke. Which
intervention should the nurse implement first?
A. Encourage oral fluids immediately
B. Assess the patient's swallowing ability before giving food, fluids, or
medications
C. Place the patient in a Trendelenburg position
D. Encourage independent ambulation immediately
Correct Answer: B. Assess the Patient's Swallowing Ability Before
Giving Food, Fluids, or Medications
Rationale:
Patients with acute stroke are at high risk for dysphagia and aspiration.
A swallowing assessment should be completed before administering
anything by mouth.
Question 2
A patient with chronic kidney disease has a serum potassium level of
6.5 mEq/L. Which electrocardiogram (ECG) finding should the nurse
anticipate?
A. Flattened T waves
B. Peaked T waves
C. Prolonged QT interval only
D. ST-segment elevation
,Correct Answer: B. Peaked T Waves
Rationale:
Hyperkalemia commonly produces tall, peaked T waves and can
progress to life-threatening dysrhythmias if untreated.
Question 3
A nurse is caring for a patient receiving a continuous heparin infusion.
Which laboratory value is most important to monitor?
A. Hemoglobin A1C
B. Activated partial thromboplastin time (aPTT)
C. Serum sodium
D. Total cholesterol
Correct Answer: B. Activated Partial Thromboplastin Time (aPTT)
Rationale:
The aPTT is monitored to ensure therapeutic anticoagulation and
reduce the risk of bleeding.
Question 4
A postoperative patient suddenly becomes restless, tachycardic, and
dyspneic. Which complication should the nurse suspect first?
A. Constipation
B. Pulmonary embolism
C. Urinary retention
D. Atelectasis only
,Correct Answer: B. Pulmonary Embolism
Rationale:
Sudden dyspnea, tachycardia, and restlessness following surgery are
classic signs of pulmonary embolism and require immediate evaluation.
Question 5
Which patient should the nurse assess first?
A. A patient reporting mild incisional pain
B. A patient with new-onset confusion and oxygen saturation of 85%
C. A patient requesting assistance with hygiene
D. A patient awaiting discharge
Correct Answer: B. A Patient With New-Onset Confusion and Oxygen
Saturation of 85%
Rationale:
Hypoxia and altered mental status indicate impaired oxygenation,
making this the highest-priority patient according to the ABC
framework.
Question 6
Which nursing intervention is most effective in preventing catheter-
associated urinary tract infections (CAUTIs)?
A. Irrigate the catheter daily
B. Remove the urinary catheter as soon as it is no longer clinically
necessary
, C. Disconnect the drainage tubing daily
D. Raise the drainage bag above bladder level
Correct Answer: B. Remove the Urinary Catheter as Soon as It Is No
Longer Clinically Necessary
Rationale:
Minimizing catheter duration is one of the most effective strategies for
preventing CAUTIs.
Question 7
A patient receiving blood transfusion develops fever, chills, and flank
pain. What should the nurse do first?
A. Continue the transfusion and reassess later
B. Stop the transfusion immediately
C. Slow the infusion rate
D. Administer acetaminophen before assessment
Correct Answer: B. Stop the Transfusion Immediately
Rationale:
These findings suggest an acute hemolytic transfusion reaction. The
transfusion should be stopped immediately while following institutional
protocols.
Question 8
Which assessment finding indicates improvement in a patient being
treated for heart failure?
