Exam 4: NUR242/ NUR 242 EXAM with Questions
and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE - 1. Neurological System Disorders - 2.
Cardiovascular System Management - 3. Endocrine System
Conditions - 4. Renal and Genitourinary Pathologies - 5.
Gastrointestinal System Alterations
1. A patient with increased intracranial pressure (ICP) is receiving mannitol. Which clinical finding
best indicates that the medication is having its therapeutic effect?
A. Blood pressure decreases from 140/90 mmHg to 120/80 mmHg
B. Urine output increases significantly to over 100 mL/hr
C. Serum osmolality decreases to 275 mOsm/kg
D. The patient exhibits a reactive bilateral pupillary light reflex
Answer: B [Correct Answer]
CORRECT ANSWER : B
Rationale: Mannitol is an osmotic diuretic that pulls fluid from the intracellular and interstitial
spaces into the vascular space, which is then excreted by the kidneys, resulting in a high urine
output and reduced ICP. A significant increase in urine output demonstrates effective osmotic
diuresis. Options A, C, and D do not directly or primarily measure the intended immediate renal
response of osmotic diuresis for ICP reduction.
2. A nurse is caring for a client admitted with acute ischemic stroke who is being evaluated for
recombinant tissue plasminogen activator (rt-PA) administration. Which finding represents an
absolute contraindication to thrombolytic therapy?
A. Onset of stroke symptoms 2.5 hours ago
B. Blood pressure of 170/95 mmHg
C. History of a non-traumatic hemorrhagic stroke 6 months ago
D. Serum glucose level of 180 mg/dL
, Answer: C [Correct Answer]
CORRECT ANSWER : C
Rationale: A history of intracranial hemorrhage or prior hemorrhagic stroke at any time is an
absolute contraindication for thrombolytic therapy due to the catastrophic risk of recurrent
bleeding. Symptom onset within 3 hours (and up to 4.5 hours in select groups) is within the
treatment window, making option A incorrect. Blood pressure can be safely managed below
185/110 mmHg prior to infusion (making B incorrect), and a glucose of 180 mg/dL does not rule
out rt-PA.
3. A patient admitted with an acute myocardial infarction (MI) suddenly develops dyspnea,
crackles throughout all lung fields, and a pink, frothy sputum. Which collaborative intervention
should the nurse anticipate first?
A. Administering sublingual nitroglycerin
B. Placing the patient in a high-Fowler's position with legs dangling
C. Initiating a continuous infusion of normal saline at 100 mL/hr
D. Administering oral metoprolol
Answer: B [Correct Answer]
CORRECT ANSWER : B
Rationale: The patient is experiencing acute pulmonary edema, a life-threatening complication
of left-sided heart failure following an MI. Placing the patient upright with legs dangling over
the side of the bed decreases venous return (preload) to the heart and reduces pulmonary
congestion. Nitroglycerin or beta-blockers may be used later, but positioning is an immediate
mechanical intervention. Intravenous fluids (Option C) would worsen fluid overload.
4. A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing chest pain.
Which ECG lead change is most indicative of an acute transmural injury of the inferior wall of
the left ventricle?
A. ST-segment elevation in leads V1, V2, and V3
B. ST-segment elevation in leads II, III, and aVF
C. ST-segment depression in leads I and aVL
D. Tall, peaked T waves in leads V5 and V6
Answer: B [Correct Answer]
, CORRECT ANSWER : B
Rationale: Leads II, III, and aVF view the inferior wall of the left ventricle, and ST-segment
elevation in these leads indicates acute inferior wall myocardial injury or infarction. Leads V1
through V3 correspond to the anteroseptal wall (Option A), and leads V5 and V6 view the lateral
wall. Reciprocal changes can appear in I and aVL, but inferior injury is directly diagnosed via
II, III, and aVF.
5. A client with Graves' disease is admitted for a thyroidectomy and is prescribed preoperative
saturated solution of potassium iodide (SSKI). What is the primary purpose of administering this
medication prior to surgery?
A. To block the peripheral conversion of thyroxine to triiodothyronine
B. To decrease the vascularity and size of the thyroid gland to reduce bleeding risk
C. To induce permanent hypothyroidism and prevent future relapses
D. To suppress the autoimmune response attacking the thyroid tissue
Answer: B [Correct Answer]
CORRECT ANSWER : B
Rationale: Iodine preparations such as SSKI are administered preoperatively in clients with
hyperthyroidism to decrease the vascularity, size, and fragility of the thyroid gland, which
minimizes the severe risk of intraoperative and postoperative hemorrhage. They temporarily
inhibit the release of thyroid hormones into the bloodstream. They do not induce permanent
destruction or address the underlying autoimmune etiology.
6. A client presents to the emergency department with confusion, lethargy, a temperature of 104.2
°F (40.1 °C), tachycardia of 145 beats/min, and blood pressure of 160/70 mmHg. The client has
a history of uncontrolled hyperthyroidism. Which condition should the nurse suspect?
A. Myxedema coma
B. Thyroid storm
C. Adrenal crisis
D. Diabetic ketoacidosis
Answer: B [Correct Answer]
CORRECT ANSWER : B
, Rationale: Thyroid storm (thyrotoxic crisis) is a life-threatening complication characterized by
extreme hypermetabolism, high fever, severe tachycardia, and altered mental status in patients
with uncontrolled hyperthyroidism. Myxedema coma involves severe hypothyroidism with
hypothermia and bradycardia (opposite findings). Adrenal crisis and DKA present with distinct
clinical pictures not primarily driven by hypermetabolic hyperthyroidism.
7. A patient with chronic kidney disease (CKD) stage 4 has a serum potassium level of 6.8 mEq/L
and peaked T waves on the ECG. Which medication should the nurse administer first to protect
the myocardium from dangerous arrhythmias?
A. Regular insulin intravenously with glucose
B. Sodium polystyrene sulfonate orally
C. Intravenous calcium gluconate
D. Intravenous loop diuretic like furosemide
Answer: C [Correct Answer]
CORRECT ANSWER : C
Rationale: When hyperkalemia causes severe ECG changes (like peaked T waves or widened
QRS complexes), the immediate life-saving priority is to protect the cardiac cell membrane by
administering intravenous calcium gluconate. While insulin/glucose and kayexalate lower serum
potassium levels, they take longer to act; calcium stabilizes the myocardium instantly without
changing the serum potassium level.
8. A client undergoes a transurethral resection of the prostate (TURP) and is placed on continuous
bladder irrigation (CBI) with normal saline. Which assessment finding requires immediate
nursing intervention?
A. The return fluid in the drainage collection bag is light pink with small clots.
B. The client reports a strong, continuous urge to urinate around the catheter.
C. The tubing shows no output into the drainage bag while the irrigation is running rapidly.
D. The client's blood pressure is 128/78 mmHg and pulse is 82 beats/min.
Answer: C [Correct Answer]
CORRECT ANSWER : C
Rationale: Lack of output from the catheter while CBI is running indicates a complete urinary
catheter blockage, typically due to blood clots or tissue debris. This leads to bladder distention,
and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE - 1. Neurological System Disorders - 2.
Cardiovascular System Management - 3. Endocrine System
Conditions - 4. Renal and Genitourinary Pathologies - 5.
Gastrointestinal System Alterations
1. A patient with increased intracranial pressure (ICP) is receiving mannitol. Which clinical finding
best indicates that the medication is having its therapeutic effect?
A. Blood pressure decreases from 140/90 mmHg to 120/80 mmHg
B. Urine output increases significantly to over 100 mL/hr
C. Serum osmolality decreases to 275 mOsm/kg
D. The patient exhibits a reactive bilateral pupillary light reflex
Answer: B [Correct Answer]
CORRECT ANSWER : B
Rationale: Mannitol is an osmotic diuretic that pulls fluid from the intracellular and interstitial
spaces into the vascular space, which is then excreted by the kidneys, resulting in a high urine
output and reduced ICP. A significant increase in urine output demonstrates effective osmotic
diuresis. Options A, C, and D do not directly or primarily measure the intended immediate renal
response of osmotic diuresis for ICP reduction.
2. A nurse is caring for a client admitted with acute ischemic stroke who is being evaluated for
recombinant tissue plasminogen activator (rt-PA) administration. Which finding represents an
absolute contraindication to thrombolytic therapy?
A. Onset of stroke symptoms 2.5 hours ago
B. Blood pressure of 170/95 mmHg
C. History of a non-traumatic hemorrhagic stroke 6 months ago
D. Serum glucose level of 180 mg/dL
, Answer: C [Correct Answer]
CORRECT ANSWER : C
Rationale: A history of intracranial hemorrhage or prior hemorrhagic stroke at any time is an
absolute contraindication for thrombolytic therapy due to the catastrophic risk of recurrent
bleeding. Symptom onset within 3 hours (and up to 4.5 hours in select groups) is within the
treatment window, making option A incorrect. Blood pressure can be safely managed below
185/110 mmHg prior to infusion (making B incorrect), and a glucose of 180 mg/dL does not rule
out rt-PA.
3. A patient admitted with an acute myocardial infarction (MI) suddenly develops dyspnea,
crackles throughout all lung fields, and a pink, frothy sputum. Which collaborative intervention
should the nurse anticipate first?
A. Administering sublingual nitroglycerin
B. Placing the patient in a high-Fowler's position with legs dangling
C. Initiating a continuous infusion of normal saline at 100 mL/hr
D. Administering oral metoprolol
Answer: B [Correct Answer]
CORRECT ANSWER : B
Rationale: The patient is experiencing acute pulmonary edema, a life-threatening complication
of left-sided heart failure following an MI. Placing the patient upright with legs dangling over
the side of the bed decreases venous return (preload) to the heart and reduces pulmonary
congestion. Nitroglycerin or beta-blockers may be used later, but positioning is an immediate
mechanical intervention. Intravenous fluids (Option C) would worsen fluid overload.
4. A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing chest pain.
Which ECG lead change is most indicative of an acute transmural injury of the inferior wall of
the left ventricle?
A. ST-segment elevation in leads V1, V2, and V3
B. ST-segment elevation in leads II, III, and aVF
C. ST-segment depression in leads I and aVL
D. Tall, peaked T waves in leads V5 and V6
Answer: B [Correct Answer]
, CORRECT ANSWER : B
Rationale: Leads II, III, and aVF view the inferior wall of the left ventricle, and ST-segment
elevation in these leads indicates acute inferior wall myocardial injury or infarction. Leads V1
through V3 correspond to the anteroseptal wall (Option A), and leads V5 and V6 view the lateral
wall. Reciprocal changes can appear in I and aVL, but inferior injury is directly diagnosed via
II, III, and aVF.
5. A client with Graves' disease is admitted for a thyroidectomy and is prescribed preoperative
saturated solution of potassium iodide (SSKI). What is the primary purpose of administering this
medication prior to surgery?
A. To block the peripheral conversion of thyroxine to triiodothyronine
B. To decrease the vascularity and size of the thyroid gland to reduce bleeding risk
C. To induce permanent hypothyroidism and prevent future relapses
D. To suppress the autoimmune response attacking the thyroid tissue
Answer: B [Correct Answer]
CORRECT ANSWER : B
Rationale: Iodine preparations such as SSKI are administered preoperatively in clients with
hyperthyroidism to decrease the vascularity, size, and fragility of the thyroid gland, which
minimizes the severe risk of intraoperative and postoperative hemorrhage. They temporarily
inhibit the release of thyroid hormones into the bloodstream. They do not induce permanent
destruction or address the underlying autoimmune etiology.
6. A client presents to the emergency department with confusion, lethargy, a temperature of 104.2
°F (40.1 °C), tachycardia of 145 beats/min, and blood pressure of 160/70 mmHg. The client has
a history of uncontrolled hyperthyroidism. Which condition should the nurse suspect?
A. Myxedema coma
B. Thyroid storm
C. Adrenal crisis
D. Diabetic ketoacidosis
Answer: B [Correct Answer]
CORRECT ANSWER : B
, Rationale: Thyroid storm (thyrotoxic crisis) is a life-threatening complication characterized by
extreme hypermetabolism, high fever, severe tachycardia, and altered mental status in patients
with uncontrolled hyperthyroidism. Myxedema coma involves severe hypothyroidism with
hypothermia and bradycardia (opposite findings). Adrenal crisis and DKA present with distinct
clinical pictures not primarily driven by hypermetabolic hyperthyroidism.
7. A patient with chronic kidney disease (CKD) stage 4 has a serum potassium level of 6.8 mEq/L
and peaked T waves on the ECG. Which medication should the nurse administer first to protect
the myocardium from dangerous arrhythmias?
A. Regular insulin intravenously with glucose
B. Sodium polystyrene sulfonate orally
C. Intravenous calcium gluconate
D. Intravenous loop diuretic like furosemide
Answer: C [Correct Answer]
CORRECT ANSWER : C
Rationale: When hyperkalemia causes severe ECG changes (like peaked T waves or widened
QRS complexes), the immediate life-saving priority is to protect the cardiac cell membrane by
administering intravenous calcium gluconate. While insulin/glucose and kayexalate lower serum
potassium levels, they take longer to act; calcium stabilizes the myocardium instantly without
changing the serum potassium level.
8. A client undergoes a transurethral resection of the prostate (TURP) and is placed on continuous
bladder irrigation (CBI) with normal saline. Which assessment finding requires immediate
nursing intervention?
A. The return fluid in the drainage collection bag is light pink with small clots.
B. The client reports a strong, continuous urge to urinate around the catheter.
C. The tubing shows no output into the drainage bag while the irrigation is running rapidly.
D. The client's blood pressure is 128/78 mmHg and pulse is 82 beats/min.
Answer: C [Correct Answer]
CORRECT ANSWER : C
Rationale: Lack of output from the catheter while CBI is running indicates a complete urinary
catheter blockage, typically due to blood clots or tissue debris. This leads to bladder distention,
