NURS 231 (PORTAGE LEARNING) EXAM 2026
LATEST UPDATE QUESTIONS AND CORRECT
VERIFIED ANSWERS ALREADY GRADED A+
The nurse is caring for a patient who had an emergency appendectomy after appendix rupture.
The morning lab results (blood) include:
Blood cultures not back yet, but gram stain is positive for gram negative bacilli, Lactate level:
3.6, K+ 4.8, BUN 29 mg/dL, Cr 2.1 mg/dL. The patient's heart rate is 98/min and blood pressure
is 99/56. Which of the following treatments does the nurse anticipate? (Select all that apply)
a) ciprofloxacin 500 mgs every 12 hours IV
b) Insert foley catheter
c) Repeat lactate level in 4 hours
d) Normal saline IV 1000 mL over 2 hours then 200mL/hour
e) norepinephrine infusion 2-10 mcgs/min IV, titrate - ANS-a) ciprofloxacin 500 mgs every 12
hours IV
b) Insert foley catheter
c) Repeat lactate level in 4 hours
d) Normal saline IV 1000 mL over 2 hours then 200mL/hour
*Patient has evidence of sepsis-induced hypoperfusion (gram stain and lactate level).
Agressive fluid administration is needed (guidelines state 30ml/kg in first 3 hours). A foley is
needed to monitor urine output during fluid administration. Norepinephrine will not be used
unless the patient develops hypotension, despite fluid administration. Patient's MAP is
currently 70.
Your client experiencing acidosis has all of the following symptoms. Which one indicates to you
that the acidosis is worsening?
a) The client is lethargic.
,b) The client's deep tendon reflexes are 2+.
c) The patient has decreased urine output.
d) Trouseau's sign is positive. - ANS-a) The client is lethargic
*This would be congruent with hypocalcemia. Hypercalemia is associated with acidosis.
The nurse is caring for a group of clients on a medical surgical unit. For which of these
individuals does the nurse provide immediate interventions to reduce the risk for pulmonary
embolism (PE)?
a) A client receiving IV fluids through a peripheral line
b) A client returning from an open reduction and internal fixation of the tibia
c) A client with diabetes and cellulitis of the leg
d) A client with fluid volume deficit and hypokalemia receiving potassium supplements - ANS-b)
A client returning from an open reduction and internal fixation of the tibia
*Surgery and perioperative immobility are very high risks for DVT and PE. Orthopedic surgery
compounds this risk.
*No evidence suggests that the client with DM is immobile, which is a risk factor for PE.
*While severe fluid volume deficit and resulting hemoconcentration may pose a risk for
thrombosis, this is not as common as thromboembolic complications after orthopedic surgery
The nurse is caring for a group of clients on a Telemetry unit. When providing client education,
which client will the nurse determine most needs information regarding preventing pulmonary
embolism (PE)?
a) A woman with a bleeding disorder
b) A man who works on a farm
c) A woman who frequently flies to Europe
d) A man admitted for a myocardial infarction - ANS-c) A woman who frequently flies to Europe
,*Individuals who engage in prolonged and frequent air travel are at higher risk for PE due to
the dependent position of the legs during long air flights.
*farmer poses a low risk due to active lifestyle
*MI is caused by a thrombus or occlusion of the coronary arteries, not of the leg veins. If the
MI client is on prolonged bedrest, the client's risk is increased.
The nurse is developing a plan of care for a client with PE. Which client problem does the nurse
establish as the priority?
a) Risk for infection related to leukocytosis
b) Inadequate nutrition related to food-drug interactions with anticoagulant therapy
c) Hypoxemia related to ventilation-perfusion mismatch
d) Insufficient knowledge related to the cause of PE - ANS-c) Hypoxemia related to ventilation-
perfusion mismatch
*Restoring adequate oxygenation and tissue perfusion takes priority. Obstruction of blood
flow through the pulmonary artery or branches impairs ability of the alveoli to deliver O2 to
the L side of the heart; the resulting hypoxemia may be profound. Initially the pt breathes
more rapidly and eliminates CO2 causing respiratory alkalosis.
*A large PE causes hypoventilation and prolonged hyperventilation causes muscle fatigue and
hypoventilation leading to respiratory acidosis.
*Although nutrition must be addressed, priorities include airway, breathing, and circulation.
The nurse is reviewing the medical record of a client with PE. What priority does the nurse set
after reviewing the blood gas result below? pH 7.46, PaCO2 30, HCO3 26, PaO2 62
a) Have the client breathe rapidly and deeply
b) Apply oxygen
c) Collaborate with the provider to increase the pH
d) Administer sodium bicarbonate - ANS-b) Apply oxygen
, *Hypoxemia is present, demonstrated by PaO2 below 80. Supplemental O2 is needed to
improve tissue perfusion. Hyperventilation triggered by hypoxemia and pain 1st leads to
respiratory alkalosis, indicated by a low PaCO2 of 30 and a high pH 7.46. Breathing more
rapidly and deeply will continue to "blow off" CO2 and cause further alkalosis.
When caring for a client with a pulmonary embolism, which priority intervention will the nurse
use to reduce anxiety?
a) Have the client breathe into a brown paper bag using pursed lips.
b) Remain with the client and provide oxygen in a calm manner.
c) Offer the client a mild sedative.
d) Allow a family member to remain in the room. - ANS-b) Remain with the client and provide
oxygen in a calm manner.
*Anxiety, agitation, tachycardia, and restlessness are early symptoms of hypoxemia, which
occurs with a PE. The priority nursing intervention is to correct hypoxemia, the underlying cause
of anxiety. O2 will help to alleviate this problem.
*Rebreathing from a brown paper bag is an intervention that increases PaCO2 during
hyperventilation, as in a panic attack; it will not provide needed O2 and tissue perfusion.
Sedation and/or allowing a family member to stay may calm the client, but will not improve
oxygenation and may delay appropriate treatment.
When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse
calls the Rapid Response Team (RRT) for intervention for which client?
a) Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has
ongoing calf pain
b) Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia
c) Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases
of both lungs
LATEST UPDATE QUESTIONS AND CORRECT
VERIFIED ANSWERS ALREADY GRADED A+
The nurse is caring for a patient who had an emergency appendectomy after appendix rupture.
The morning lab results (blood) include:
Blood cultures not back yet, but gram stain is positive for gram negative bacilli, Lactate level:
3.6, K+ 4.8, BUN 29 mg/dL, Cr 2.1 mg/dL. The patient's heart rate is 98/min and blood pressure
is 99/56. Which of the following treatments does the nurse anticipate? (Select all that apply)
a) ciprofloxacin 500 mgs every 12 hours IV
b) Insert foley catheter
c) Repeat lactate level in 4 hours
d) Normal saline IV 1000 mL over 2 hours then 200mL/hour
e) norepinephrine infusion 2-10 mcgs/min IV, titrate - ANS-a) ciprofloxacin 500 mgs every 12
hours IV
b) Insert foley catheter
c) Repeat lactate level in 4 hours
d) Normal saline IV 1000 mL over 2 hours then 200mL/hour
*Patient has evidence of sepsis-induced hypoperfusion (gram stain and lactate level).
Agressive fluid administration is needed (guidelines state 30ml/kg in first 3 hours). A foley is
needed to monitor urine output during fluid administration. Norepinephrine will not be used
unless the patient develops hypotension, despite fluid administration. Patient's MAP is
currently 70.
Your client experiencing acidosis has all of the following symptoms. Which one indicates to you
that the acidosis is worsening?
a) The client is lethargic.
,b) The client's deep tendon reflexes are 2+.
c) The patient has decreased urine output.
d) Trouseau's sign is positive. - ANS-a) The client is lethargic
*This would be congruent with hypocalcemia. Hypercalemia is associated with acidosis.
The nurse is caring for a group of clients on a medical surgical unit. For which of these
individuals does the nurse provide immediate interventions to reduce the risk for pulmonary
embolism (PE)?
a) A client receiving IV fluids through a peripheral line
b) A client returning from an open reduction and internal fixation of the tibia
c) A client with diabetes and cellulitis of the leg
d) A client with fluid volume deficit and hypokalemia receiving potassium supplements - ANS-b)
A client returning from an open reduction and internal fixation of the tibia
*Surgery and perioperative immobility are very high risks for DVT and PE. Orthopedic surgery
compounds this risk.
*No evidence suggests that the client with DM is immobile, which is a risk factor for PE.
*While severe fluid volume deficit and resulting hemoconcentration may pose a risk for
thrombosis, this is not as common as thromboembolic complications after orthopedic surgery
The nurse is caring for a group of clients on a Telemetry unit. When providing client education,
which client will the nurse determine most needs information regarding preventing pulmonary
embolism (PE)?
a) A woman with a bleeding disorder
b) A man who works on a farm
c) A woman who frequently flies to Europe
d) A man admitted for a myocardial infarction - ANS-c) A woman who frequently flies to Europe
,*Individuals who engage in prolonged and frequent air travel are at higher risk for PE due to
the dependent position of the legs during long air flights.
*farmer poses a low risk due to active lifestyle
*MI is caused by a thrombus or occlusion of the coronary arteries, not of the leg veins. If the
MI client is on prolonged bedrest, the client's risk is increased.
The nurse is developing a plan of care for a client with PE. Which client problem does the nurse
establish as the priority?
a) Risk for infection related to leukocytosis
b) Inadequate nutrition related to food-drug interactions with anticoagulant therapy
c) Hypoxemia related to ventilation-perfusion mismatch
d) Insufficient knowledge related to the cause of PE - ANS-c) Hypoxemia related to ventilation-
perfusion mismatch
*Restoring adequate oxygenation and tissue perfusion takes priority. Obstruction of blood
flow through the pulmonary artery or branches impairs ability of the alveoli to deliver O2 to
the L side of the heart; the resulting hypoxemia may be profound. Initially the pt breathes
more rapidly and eliminates CO2 causing respiratory alkalosis.
*A large PE causes hypoventilation and prolonged hyperventilation causes muscle fatigue and
hypoventilation leading to respiratory acidosis.
*Although nutrition must be addressed, priorities include airway, breathing, and circulation.
The nurse is reviewing the medical record of a client with PE. What priority does the nurse set
after reviewing the blood gas result below? pH 7.46, PaCO2 30, HCO3 26, PaO2 62
a) Have the client breathe rapidly and deeply
b) Apply oxygen
c) Collaborate with the provider to increase the pH
d) Administer sodium bicarbonate - ANS-b) Apply oxygen
, *Hypoxemia is present, demonstrated by PaO2 below 80. Supplemental O2 is needed to
improve tissue perfusion. Hyperventilation triggered by hypoxemia and pain 1st leads to
respiratory alkalosis, indicated by a low PaCO2 of 30 and a high pH 7.46. Breathing more
rapidly and deeply will continue to "blow off" CO2 and cause further alkalosis.
When caring for a client with a pulmonary embolism, which priority intervention will the nurse
use to reduce anxiety?
a) Have the client breathe into a brown paper bag using pursed lips.
b) Remain with the client and provide oxygen in a calm manner.
c) Offer the client a mild sedative.
d) Allow a family member to remain in the room. - ANS-b) Remain with the client and provide
oxygen in a calm manner.
*Anxiety, agitation, tachycardia, and restlessness are early symptoms of hypoxemia, which
occurs with a PE. The priority nursing intervention is to correct hypoxemia, the underlying cause
of anxiety. O2 will help to alleviate this problem.
*Rebreathing from a brown paper bag is an intervention that increases PaCO2 during
hyperventilation, as in a panic attack; it will not provide needed O2 and tissue perfusion.
Sedation and/or allowing a family member to stay may calm the client, but will not improve
oxygenation and may delay appropriate treatment.
When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse
calls the Rapid Response Team (RRT) for intervention for which client?
a) Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has
ongoing calf pain
b) Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia
c) Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases
of both lungs
