NUR 231 Exam 4 – Adult Nursing II (2026)
Actual Questions & Verified Answers |
Illinois State University (A+ Guarantee)
1. A client with acute leukemia is receiving induction chemotherapy. Which
assessment finding requires the nurse's priority action?
A. Mild fatigue after ambulation
B. Temperature of 38.3°C (100.9°F)
C. Decreased appetite
D. Alopecia
Answer: B. Temperature of 38.3°C (100.9°F)
Rationale: A client receiving intensive chemotherapy is at high risk for
neutropenia and serious infection. Fever may be the first indication of infection
and requires prompt assessment and intervention. Fatigue, appetite changes, and
alopecia are common treatment effects but are not immediately life-threatening.
2. A client with acute leukemia has a platelet count of 18,000/mm³. Which
nursing intervention is most appropriate?
A. Encourage vigorous tooth brushing
B. Administer intramuscular injections as prescribed
C. Implement bleeding precautions
D. Encourage contact sports
Answer: C. Implement bleeding precautions
Rationale: Severe thrombocytopenia substantially increases the risk of
spontaneous bleeding. Bleeding precautions include avoiding unnecessary
invasive procedures, using a soft toothbrush when appropriate, preventing
injury, and monitoring for bleeding.
,3. A client receiving chemotherapy develops laboratory findings consistent
with tumor lysis syndrome. Which electrolyte abnormality should the nurse
anticipate?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypophosphatemia
Answer: B. Hyperkalemia
Rationale: Rapid destruction of malignant cells releases intracellular contents
into the bloodstream. Tumor lysis syndrome can produce hyperkalemia,
hyperphosphatemia, hypocalcemia, and hyperuricemia, potentially causing
dysrhythmias and acute kidney injury.
4. Which finding in a client receiving chemotherapy is most suggestive of
stomatitis?
A. Blurred vision
B. Painful oral ulcers
C. Bilateral ankle edema
D. Increased urinary frequency
Answer: B. Painful oral ulcers
Rationale: Chemotherapy can damage rapidly dividing cells of the oral mucosa,
producing stomatitis, erythema, ulceration, and pain. Oral care and avoidance of
irritating foods can help reduce complications.
5. A client with multiple myeloma is at increased risk for which complication?
A. Hypercalcemia
B. Hypoglycemia
C. Severe hypernatremia
D. Metabolic alkalosis
Answer: A. Hypercalcemia
,Rationale: Bone destruction associated with multiple myeloma can release
calcium into the bloodstream. Hypercalcemia may cause weakness, constipation,
confusion, polyuria, and cardiac abnormalities.
6. Which statement best describes the primary goal of hospice care?
A. Cure the underlying disease
B. Prolong life through aggressive treatment
C. Promote comfort and quality of life
D. Reverse functional decline
Answer: C. Promote comfort and quality of life
Rationale: Hospice care focuses on comfort, symptom management, dignity, and
quality of life for individuals approaching the end of life. Curative treatment is
not the primary goal.
7. A dying client develops irregular respirations with periods of apnea. How
should the nurse interpret this finding?
A. It is always evidence of acute respiratory infection
B. It may occur as part of the dying process
C. It indicates immediate recovery
D. It confirms pulmonary embolism
Answer: B. It may occur as part of the dying process
Rationale: Changes in respiratory pattern, including periods of apnea and
irregular breathing, commonly occur near death. Nursing care should
emphasize comfort, symptom management, and support for the client and family.
8. A client has a do-not-resuscitate order. The client becomes pulseless. Which
action should the nurse take?
A. Begin chest compressions immediately
B. Initiate defibrillation
C. Follow the established DNR order and provide appropriate comfort measures
D. Ask the family whether CPR should be started
Answer: C. Follow the established DNR order and provide appropriate comfort
measures
, Rationale: A valid DNR order indicates that cardiopulmonary resuscitation
should not be initiated. The nurse should continue appropriate nursing care and
comfort measures consistent with the client's goals.
9. A client develops a suspected acute hemolytic transfusion reaction. Which
action should the nurse take first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer another unit of blood
D. Flush the blood tubing with additional blood
Answer: B. Stop the transfusion
Rationale: The transfusion must be stopped immediately when a serious reaction
is suspected. The nurse should maintain IV access according to institutional
protocol, assess the client, notify the appropriate provider and blood bank, and
follow the facility's transfusion-reaction procedure.
10. Which finding is most concerning for an acute hemolytic transfusion
reaction?
A. Mild hunger
B. Flank or lower back pain with fever and chills
C. Increased appetite
D. Gradual hair loss
Answer: B. Flank or lower back pain with fever and chills
Rationale: Acute hemolytic reactions can produce fever, chills, back or flank
pain, hypotension, dyspnea, and hemoglobinuria. Immediate intervention is
required because the reaction can progress rapidly.
11. Which assessment finding is commonly associated with peptic ulcer
disease?
A. Epigastric discomfort
B. Severe hearing loss
C. Peripheral cyanosis
D. Urinary retention
Actual Questions & Verified Answers |
Illinois State University (A+ Guarantee)
1. A client with acute leukemia is receiving induction chemotherapy. Which
assessment finding requires the nurse's priority action?
A. Mild fatigue after ambulation
B. Temperature of 38.3°C (100.9°F)
C. Decreased appetite
D. Alopecia
Answer: B. Temperature of 38.3°C (100.9°F)
Rationale: A client receiving intensive chemotherapy is at high risk for
neutropenia and serious infection. Fever may be the first indication of infection
and requires prompt assessment and intervention. Fatigue, appetite changes, and
alopecia are common treatment effects but are not immediately life-threatening.
2. A client with acute leukemia has a platelet count of 18,000/mm³. Which
nursing intervention is most appropriate?
A. Encourage vigorous tooth brushing
B. Administer intramuscular injections as prescribed
C. Implement bleeding precautions
D. Encourage contact sports
Answer: C. Implement bleeding precautions
Rationale: Severe thrombocytopenia substantially increases the risk of
spontaneous bleeding. Bleeding precautions include avoiding unnecessary
invasive procedures, using a soft toothbrush when appropriate, preventing
injury, and monitoring for bleeding.
,3. A client receiving chemotherapy develops laboratory findings consistent
with tumor lysis syndrome. Which electrolyte abnormality should the nurse
anticipate?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypophosphatemia
Answer: B. Hyperkalemia
Rationale: Rapid destruction of malignant cells releases intracellular contents
into the bloodstream. Tumor lysis syndrome can produce hyperkalemia,
hyperphosphatemia, hypocalcemia, and hyperuricemia, potentially causing
dysrhythmias and acute kidney injury.
4. Which finding in a client receiving chemotherapy is most suggestive of
stomatitis?
A. Blurred vision
B. Painful oral ulcers
C. Bilateral ankle edema
D. Increased urinary frequency
Answer: B. Painful oral ulcers
Rationale: Chemotherapy can damage rapidly dividing cells of the oral mucosa,
producing stomatitis, erythema, ulceration, and pain. Oral care and avoidance of
irritating foods can help reduce complications.
5. A client with multiple myeloma is at increased risk for which complication?
A. Hypercalcemia
B. Hypoglycemia
C. Severe hypernatremia
D. Metabolic alkalosis
Answer: A. Hypercalcemia
,Rationale: Bone destruction associated with multiple myeloma can release
calcium into the bloodstream. Hypercalcemia may cause weakness, constipation,
confusion, polyuria, and cardiac abnormalities.
6. Which statement best describes the primary goal of hospice care?
A. Cure the underlying disease
B. Prolong life through aggressive treatment
C. Promote comfort and quality of life
D. Reverse functional decline
Answer: C. Promote comfort and quality of life
Rationale: Hospice care focuses on comfort, symptom management, dignity, and
quality of life for individuals approaching the end of life. Curative treatment is
not the primary goal.
7. A dying client develops irregular respirations with periods of apnea. How
should the nurse interpret this finding?
A. It is always evidence of acute respiratory infection
B. It may occur as part of the dying process
C. It indicates immediate recovery
D. It confirms pulmonary embolism
Answer: B. It may occur as part of the dying process
Rationale: Changes in respiratory pattern, including periods of apnea and
irregular breathing, commonly occur near death. Nursing care should
emphasize comfort, symptom management, and support for the client and family.
8. A client has a do-not-resuscitate order. The client becomes pulseless. Which
action should the nurse take?
A. Begin chest compressions immediately
B. Initiate defibrillation
C. Follow the established DNR order and provide appropriate comfort measures
D. Ask the family whether CPR should be started
Answer: C. Follow the established DNR order and provide appropriate comfort
measures
, Rationale: A valid DNR order indicates that cardiopulmonary resuscitation
should not be initiated. The nurse should continue appropriate nursing care and
comfort measures consistent with the client's goals.
9. A client develops a suspected acute hemolytic transfusion reaction. Which
action should the nurse take first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer another unit of blood
D. Flush the blood tubing with additional blood
Answer: B. Stop the transfusion
Rationale: The transfusion must be stopped immediately when a serious reaction
is suspected. The nurse should maintain IV access according to institutional
protocol, assess the client, notify the appropriate provider and blood bank, and
follow the facility's transfusion-reaction procedure.
10. Which finding is most concerning for an acute hemolytic transfusion
reaction?
A. Mild hunger
B. Flank or lower back pain with fever and chills
C. Increased appetite
D. Gradual hair loss
Answer: B. Flank or lower back pain with fever and chills
Rationale: Acute hemolytic reactions can produce fever, chills, back or flank
pain, hypotension, dyspnea, and hemoglobinuria. Immediate intervention is
required because the reaction can progress rapidly.
11. Which assessment finding is commonly associated with peptic ulcer
disease?
A. Epigastric discomfort
B. Severe hearing loss
C. Peripheral cyanosis
D. Urinary retention
