NUR 215 Exam 2 Questions With Correct
Answers (Verified Answers) Plus Rationales
2026 Q&A | Instant Download Pdf
1. A nurse is caring for a client diagnosed with heart failure. Which
assessment finding indicates worsening left-sided heart failure?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in the lungs
D. Hepatomegaly
Rationale: Left-sided heart failure primarily causes pulmonary
congestion because the left ventricle cannot effectively pump blood
forward. This results in fluid backing up into the pulmonary
circulation, producing crackles, dyspnea, orthopnea, and decreased
oxygenation. Jugular vein distention, hepatomegaly, and peripheral
edema are more characteristic of right-sided heart failure.
2. Which electrolyte imbalance places a client at the greatest risk for
developing cardiac dysrhythmias?
,A. Mild hypercalcemia
B. Hypokalemia
C. Hypermagnesemia
D. Hyponatremia
Rationale: Potassium plays a critical role in cardiac electrical
conduction. Hypokalemia increases myocardial excitability and may
lead to life-threatening dysrhythmias such as ventricular tachycardia
and ventricular fibrillation. Prompt recognition and correction are
essential.
3. A nurse is teaching a client prescribed warfarin. Which statement
by the client indicates correct understanding?
A. "I will stop taking the medication if I notice bruising."
B. "I should avoid all green vegetables."
C. "I should have my INR checked regularly."
D. "I can take aspirin whenever I have pain."
Rationale: Clients taking warfarin require regular INR monitoring to
ensure therapeutic anticoagulation while minimizing bleeding risk.
Vitamin K-containing foods should remain consistent rather than
eliminated, and aspirin should be avoided unless specifically
prescribed.
, 4. Which assessment finding requires immediate intervention for a
client receiving intravenous potassium chloride?
A. Urine output of 40 mL/hr
B. Mild nausea
C. Burning and redness at the IV site
D. Heart rate of 72 beats/min
Rationale: Potassium chloride is highly irritating to veins. Burning and
redness at the infusion site suggest infiltration or phlebitis, requiring
immediate discontinuation of the infusion and assessment of the IV
site.
5. Which laboratory value is most concerning for a client with
chronic kidney disease?
A. Hemoglobin 12.8 g/dL
B. Sodium 138 mEq/L
C. Potassium 6.2 mEq/L
D. Calcium 9.1 mg/dL
Rationale: Hyperkalemia is a life-threatening complication of chronic
kidney disease because impaired renal function limits potassium
excretion. Severe hyperkalemia may cause fatal cardiac dysrhythmias
and requires immediate treatment.
, 6. A client with chronic obstructive pulmonary disease (COPD)
should receive oxygen therapy with which goal?
A. Oxygen saturation above 100%
B. Oxygen saturation between 88% and 92%
C. Oxygen saturation above 98% at all times
D. Oxygen saturation between 70% and 80%
Rationale: Clients with COPD often require carefully controlled oxygen
therapy to maintain adequate oxygenation while minimizing the risk
of suppressing respiratory drive. A target oxygen saturation of
approximately 88% to 92% is commonly appropriate unless otherwise
prescribed.
7. Which client should the nurse assess first?
A. Client with a temperature of 100.4°F (38°C)
B. Client requesting pain medication rated 6/10
C. Client awaiting discharge instructions
D. Client reporting sudden chest pain and shortness of breath
Rationale: Sudden chest pain accompanied by shortness of breath may
indicate myocardial infarction, pulmonary embolism, or another life-
threatening condition. Airway, breathing, and circulation take priority
over less urgent concerns.
Answers (Verified Answers) Plus Rationales
2026 Q&A | Instant Download Pdf
1. A nurse is caring for a client diagnosed with heart failure. Which
assessment finding indicates worsening left-sided heart failure?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in the lungs
D. Hepatomegaly
Rationale: Left-sided heart failure primarily causes pulmonary
congestion because the left ventricle cannot effectively pump blood
forward. This results in fluid backing up into the pulmonary
circulation, producing crackles, dyspnea, orthopnea, and decreased
oxygenation. Jugular vein distention, hepatomegaly, and peripheral
edema are more characteristic of right-sided heart failure.
2. Which electrolyte imbalance places a client at the greatest risk for
developing cardiac dysrhythmias?
,A. Mild hypercalcemia
B. Hypokalemia
C. Hypermagnesemia
D. Hyponatremia
Rationale: Potassium plays a critical role in cardiac electrical
conduction. Hypokalemia increases myocardial excitability and may
lead to life-threatening dysrhythmias such as ventricular tachycardia
and ventricular fibrillation. Prompt recognition and correction are
essential.
3. A nurse is teaching a client prescribed warfarin. Which statement
by the client indicates correct understanding?
A. "I will stop taking the medication if I notice bruising."
B. "I should avoid all green vegetables."
C. "I should have my INR checked regularly."
D. "I can take aspirin whenever I have pain."
Rationale: Clients taking warfarin require regular INR monitoring to
ensure therapeutic anticoagulation while minimizing bleeding risk.
Vitamin K-containing foods should remain consistent rather than
eliminated, and aspirin should be avoided unless specifically
prescribed.
, 4. Which assessment finding requires immediate intervention for a
client receiving intravenous potassium chloride?
A. Urine output of 40 mL/hr
B. Mild nausea
C. Burning and redness at the IV site
D. Heart rate of 72 beats/min
Rationale: Potassium chloride is highly irritating to veins. Burning and
redness at the infusion site suggest infiltration or phlebitis, requiring
immediate discontinuation of the infusion and assessment of the IV
site.
5. Which laboratory value is most concerning for a client with
chronic kidney disease?
A. Hemoglobin 12.8 g/dL
B. Sodium 138 mEq/L
C. Potassium 6.2 mEq/L
D. Calcium 9.1 mg/dL
Rationale: Hyperkalemia is a life-threatening complication of chronic
kidney disease because impaired renal function limits potassium
excretion. Severe hyperkalemia may cause fatal cardiac dysrhythmias
and requires immediate treatment.
, 6. A client with chronic obstructive pulmonary disease (COPD)
should receive oxygen therapy with which goal?
A. Oxygen saturation above 100%
B. Oxygen saturation between 88% and 92%
C. Oxygen saturation above 98% at all times
D. Oxygen saturation between 70% and 80%
Rationale: Clients with COPD often require carefully controlled oxygen
therapy to maintain adequate oxygenation while minimizing the risk
of suppressing respiratory drive. A target oxygen saturation of
approximately 88% to 92% is commonly appropriate unless otherwise
prescribed.
7. Which client should the nurse assess first?
A. Client with a temperature of 100.4°F (38°C)
B. Client requesting pain medication rated 6/10
C. Client awaiting discharge instructions
D. Client reporting sudden chest pain and shortness of breath
Rationale: Sudden chest pain accompanied by shortness of breath may
indicate myocardial infarction, pulmonary embolism, or another life-
threatening condition. Airway, breathing, and circulation take priority
over less urgent concerns.
