1
. NR 228 FINAL EXAM/NR 228 FINAL EXAM
PREPARATION/NR 228 FINAL EXAM PRACTICE
REAL EXAM 150 QUESTIONS AND CORRECT
ANSWERS| AGRADE|CHAMBERLAIN COLLEGE OF
NURSING 1.
A nurse is caring for a client who was admitted to the medical-surgical
unit with a diagnosis of acute heart failure. During the morning
assessment, the client reports increasing shortness of breath and
difficulty breathing when lying flat. The nurse observes bilateral
crackles in the lung bases, an oxygen saturation of 88% on room air, and
3+ bilateral lower-extremity edema. Which intervention should the nurse
implement first?
A. Administer the prescribed loop diuretic and reassess the client's urine
output
B. Place the client in high-Fowler's position and administer oxygen as
prescribed
C. Encourage the client to increase oral fluid intake to improve cardiac
output
D. Obtain the client's weight and document the findings in the medical
record
Correct answer: B
2.
A client with type 1 diabetes mellitus is admitted to the emergency
department with nausea, vomiting, abdominal pain, excessive thirst, and
frequent urination. Laboratory results reveal a blood glucose level of 486
mg/dL, arterial pH of 7.21, and positive serum ketones. The client is
dehydrated and has deep, rapid respirations. Which condition should the
nurse recognize as the most likely cause of these findings?
,2
A. Hyperosmolar hyperglycemic state
B. Diabetic ketoacidosis
C. Hypoglycemic emergency
D. Syndrome of inappropriate antidiuretic hormone secretion
Correct answer: B
3.
A nurse is caring for an older adult client who has been prescribed
digoxin for management of heart failure. Before administering the
medication, the nurse assesses the client's apical pulse and obtains a rate
of 54 beats/min. The client also reports nausea and seeing yellow-green
halos around objects. Which action should the nurse take?
A. Administer the medication because the pulse is within the expected
range
B. Administer the medication with food to decrease gastrointestinal
effects
C. Hold the medication and notify the healthcare provider
D. Administer an additional dose to improve cardiac contractility
Correct answer: C
4.
A client with chronic obstructive pulmonary disease is receiving oxygen
therapy through a nasal cannula. The client becomes increasingly
drowsy and difficult to arouse after the oxygen flow rate is increased
significantly. The nurse notes shallow respirations and a decreasing
respiratory rate. Which complication should the nurse suspect?
,3
A. Acute pulmonary embolism
B. Carbon monoxide poisoning
C. Oxygen-induced hypoventilation with carbon dioxide retention
D. Acute respiratory alkalosis caused by excessive ventilation
Correct answer: C
5.
A nurse is caring for a client who has been receiving intravenous
unfractionated heparin for treatment of a pulmonary embolism. The
client's laboratory results reveal a significantly elevated activated partial
thromboplastin time, and the client develops bleeding from the gums and
blood in the urine. Which medication should the nurse anticipate
administering as the antidote?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Acetylcysteine
Correct answer: B
6.
A client is admitted with a suspected acute myocardial infarction and
reports severe crushing substernal chest pain that radiates to the left arm
and jaw. The client is pale, diaphoretic, and anxious. Which prescribed
medication should the nurse anticipate administering first to help relieve
the client's ischemic chest discomfort, assuming there are no
contraindications?
, 4
A. Sublingual nitroglycerin
B. Oral warfarin
C. Intramuscular vitamin K
D. Oral potassium chloride
Correct answer: A
7.
A nurse is assessing a client who has developed a sudden unilateral
weakness of the right arm and leg, facial drooping, and difficulty
speaking. The client's symptoms began approximately 45 minutes ago
while the client was eating breakfast. Which action is the nurse's
priority?
A. Give the client oral fluids to prevent dehydration
B. Determine the exact time the symptoms began and activate the stroke
response
C. Place the client in Trendelenburg position
D. Administer aspirin without obtaining further assessment data
Correct answer: B
8.
A client who underwent abdominal surgery 24 hours ago suddenly
develops shortness of breath, chest pain, tachycardia, and anxiety. The
nurse observes an oxygen saturation of 86% and rapid respirations. The
client has been mostly immobile since surgery. Which complication
should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
. NR 228 FINAL EXAM/NR 228 FINAL EXAM
PREPARATION/NR 228 FINAL EXAM PRACTICE
REAL EXAM 150 QUESTIONS AND CORRECT
ANSWERS| AGRADE|CHAMBERLAIN COLLEGE OF
NURSING 1.
A nurse is caring for a client who was admitted to the medical-surgical
unit with a diagnosis of acute heart failure. During the morning
assessment, the client reports increasing shortness of breath and
difficulty breathing when lying flat. The nurse observes bilateral
crackles in the lung bases, an oxygen saturation of 88% on room air, and
3+ bilateral lower-extremity edema. Which intervention should the nurse
implement first?
A. Administer the prescribed loop diuretic and reassess the client's urine
output
B. Place the client in high-Fowler's position and administer oxygen as
prescribed
C. Encourage the client to increase oral fluid intake to improve cardiac
output
D. Obtain the client's weight and document the findings in the medical
record
Correct answer: B
2.
A client with type 1 diabetes mellitus is admitted to the emergency
department with nausea, vomiting, abdominal pain, excessive thirst, and
frequent urination. Laboratory results reveal a blood glucose level of 486
mg/dL, arterial pH of 7.21, and positive serum ketones. The client is
dehydrated and has deep, rapid respirations. Which condition should the
nurse recognize as the most likely cause of these findings?
,2
A. Hyperosmolar hyperglycemic state
B. Diabetic ketoacidosis
C. Hypoglycemic emergency
D. Syndrome of inappropriate antidiuretic hormone secretion
Correct answer: B
3.
A nurse is caring for an older adult client who has been prescribed
digoxin for management of heart failure. Before administering the
medication, the nurse assesses the client's apical pulse and obtains a rate
of 54 beats/min. The client also reports nausea and seeing yellow-green
halos around objects. Which action should the nurse take?
A. Administer the medication because the pulse is within the expected
range
B. Administer the medication with food to decrease gastrointestinal
effects
C. Hold the medication and notify the healthcare provider
D. Administer an additional dose to improve cardiac contractility
Correct answer: C
4.
A client with chronic obstructive pulmonary disease is receiving oxygen
therapy through a nasal cannula. The client becomes increasingly
drowsy and difficult to arouse after the oxygen flow rate is increased
significantly. The nurse notes shallow respirations and a decreasing
respiratory rate. Which complication should the nurse suspect?
,3
A. Acute pulmonary embolism
B. Carbon monoxide poisoning
C. Oxygen-induced hypoventilation with carbon dioxide retention
D. Acute respiratory alkalosis caused by excessive ventilation
Correct answer: C
5.
A nurse is caring for a client who has been receiving intravenous
unfractionated heparin for treatment of a pulmonary embolism. The
client's laboratory results reveal a significantly elevated activated partial
thromboplastin time, and the client develops bleeding from the gums and
blood in the urine. Which medication should the nurse anticipate
administering as the antidote?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Acetylcysteine
Correct answer: B
6.
A client is admitted with a suspected acute myocardial infarction and
reports severe crushing substernal chest pain that radiates to the left arm
and jaw. The client is pale, diaphoretic, and anxious. Which prescribed
medication should the nurse anticipate administering first to help relieve
the client's ischemic chest discomfort, assuming there are no
contraindications?
, 4
A. Sublingual nitroglycerin
B. Oral warfarin
C. Intramuscular vitamin K
D. Oral potassium chloride
Correct answer: A
7.
A nurse is assessing a client who has developed a sudden unilateral
weakness of the right arm and leg, facial drooping, and difficulty
speaking. The client's symptoms began approximately 45 minutes ago
while the client was eating breakfast. Which action is the nurse's
priority?
A. Give the client oral fluids to prevent dehydration
B. Determine the exact time the symptoms began and activate the stroke
response
C. Place the client in Trendelenburg position
D. Administer aspirin without obtaining further assessment data
Correct answer: B
8.
A client who underwent abdominal surgery 24 hours ago suddenly
develops shortness of breath, chest pain, tachycardia, and anxiety. The
nurse observes an oxygen saturation of 86% and rapid respirations. The
client has been mostly immobile since surgery. Which complication
should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
