NSG 5544 EXAM 2 — PRACTICE ACTUAL EXAM ALL
QUESTIONS AND ANSWERS ALREADY GRADED A+. 100%
VERIFIED SOLUTIONS | UPDATED PER LATEST
GUIDELINES | GRADED A+,
Questions 1–25
1. A client with heart failure reports increasing dyspnea, orthopnea, and a 3-kg weight gain
over 4 days. Which finding is most concerning?
A. Mild fatigue
B. Bilateral ankle edema
C. Oxygen saturation of 86%
D. Heart rate of 92/min
Answer: C
Rationale: An oxygen saturation of 86% indicates significant hypoxemia and requires immediate
intervention. Dyspnea and fluid retention support worsening heart failure, but impaired
oxygenation is the immediate priority.
2. A client with chronic heart failure is prescribed furosemide. Which laboratory value is most
important to monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: B
Rationale: Furosemide is a loop diuretic that can cause potassium loss. Hypokalemia increases
the risk of dysrhythmias.
,3. A client receiving an ACE inhibitor develops facial swelling and difficulty breathing. Which
action should the nurse take first?
A. Administer the next dose
B. Place the client in a supine position
C. Discontinue the medication and initiate emergency management
D. Reassure the client that this is expected
Answer: C
Rationale: Facial swelling and respiratory difficulty suggest angioedema, a potentially life-
threatening adverse effect of ACE inhibitors.
4. Which assessment finding is most consistent with left-sided heart failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C
Rationale: Left-sided heart failure causes pulmonary congestion, resulting in crackles, dyspnea,
and orthopnea. Right-sided failure more commonly causes systemic venous congestion.
5. A client with atrial fibrillation is prescribed apixaban. Which finding should the nurse report
immediately?
A. Mild fatigue
B. Black, tarry stool
C. Heart rate of 82/min
D. Occasional headache
Answer: B
Rationale: Melena may indicate gastrointestinal bleeding. Anticoagulants increase bleeding risk.
,6. A client taking warfarin asks which laboratory test is used to monitor therapy. Which
response is correct?
A. aPTT
B. INR
C. Troponin
D. BNP
Answer: B
Rationale: Warfarin therapy is monitored primarily using the PT/INR.
7. A client with suspected myocardial infarction reports crushing substernal chest pain
radiating to the left arm. Which action is the priority?
A. Obtain a detailed dietary history
B. Initiate rapid cardiac assessment and obtain a 12-lead ECG
C. Encourage ambulation
D. Provide a meal
Answer: B
Rationale: Rapid identification of myocardial ischemia is essential. A 12-lead ECG should be
obtained promptly in suspected acute coronary syndrome.
8. Which laboratory marker is most specific for myocardial injury?
A. BNP
B. Troponin
C. D-dimer
D. Creatinine
Answer: B
Rationale: Cardiac troponins are highly sensitive and specific markers of myocardial injury.
9. A client with COPD is receiving oxygen. Which nursing action is appropriate?
A. Administer unlimited high-flow oxygen
B. Titrate oxygen according to the prescribed target and clinical condition
, C. Discontinue oxygen if the client becomes dyspneic
D. Avoid monitoring oxygen saturation
Answer: B
Rationale: Oxygen should be carefully titrated to the prescribed target, commonly around 88–
92% for many patients with COPD who are at risk of hypercapnic respiratory failure, depending
on the clinical situation.
10. Which finding is characteristic of emphysema?
A. Productive cough with large amounts of sputum
B. Hyperinflation and decreased breath sounds
C. Massive hemoptysis
D. Sudden unilateral pleuritic pain
Answer: B
Rationale: Emphysema causes destruction of alveolar walls, air trapping, hyperinflation, and
decreased breath sounds.
11. A client with asthma develops severe wheezing followed by markedly decreased breath
sounds. What does this finding indicate?
A. Improvement
B. Severe airflow obstruction
C. Normal asthma progression
D. Resolution of bronchospasm
Answer: B
Rationale: A "silent chest" or markedly diminished breath sounds in severe asthma can indicate
critically reduced airflow and impending respiratory failure.
12. Which medication is commonly used as a rapid-relief bronchodilator for acute asthma
symptoms?
A. Salmeterol
B. Albuterol
QUESTIONS AND ANSWERS ALREADY GRADED A+. 100%
VERIFIED SOLUTIONS | UPDATED PER LATEST
GUIDELINES | GRADED A+,
Questions 1–25
1. A client with heart failure reports increasing dyspnea, orthopnea, and a 3-kg weight gain
over 4 days. Which finding is most concerning?
A. Mild fatigue
B. Bilateral ankle edema
C. Oxygen saturation of 86%
D. Heart rate of 92/min
Answer: C
Rationale: An oxygen saturation of 86% indicates significant hypoxemia and requires immediate
intervention. Dyspnea and fluid retention support worsening heart failure, but impaired
oxygenation is the immediate priority.
2. A client with chronic heart failure is prescribed furosemide. Which laboratory value is most
important to monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: B
Rationale: Furosemide is a loop diuretic that can cause potassium loss. Hypokalemia increases
the risk of dysrhythmias.
,3. A client receiving an ACE inhibitor develops facial swelling and difficulty breathing. Which
action should the nurse take first?
A. Administer the next dose
B. Place the client in a supine position
C. Discontinue the medication and initiate emergency management
D. Reassure the client that this is expected
Answer: C
Rationale: Facial swelling and respiratory difficulty suggest angioedema, a potentially life-
threatening adverse effect of ACE inhibitors.
4. Which assessment finding is most consistent with left-sided heart failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C
Rationale: Left-sided heart failure causes pulmonary congestion, resulting in crackles, dyspnea,
and orthopnea. Right-sided failure more commonly causes systemic venous congestion.
5. A client with atrial fibrillation is prescribed apixaban. Which finding should the nurse report
immediately?
A. Mild fatigue
B. Black, tarry stool
C. Heart rate of 82/min
D. Occasional headache
Answer: B
Rationale: Melena may indicate gastrointestinal bleeding. Anticoagulants increase bleeding risk.
,6. A client taking warfarin asks which laboratory test is used to monitor therapy. Which
response is correct?
A. aPTT
B. INR
C. Troponin
D. BNP
Answer: B
Rationale: Warfarin therapy is monitored primarily using the PT/INR.
7. A client with suspected myocardial infarction reports crushing substernal chest pain
radiating to the left arm. Which action is the priority?
A. Obtain a detailed dietary history
B. Initiate rapid cardiac assessment and obtain a 12-lead ECG
C. Encourage ambulation
D. Provide a meal
Answer: B
Rationale: Rapid identification of myocardial ischemia is essential. A 12-lead ECG should be
obtained promptly in suspected acute coronary syndrome.
8. Which laboratory marker is most specific for myocardial injury?
A. BNP
B. Troponin
C. D-dimer
D. Creatinine
Answer: B
Rationale: Cardiac troponins are highly sensitive and specific markers of myocardial injury.
9. A client with COPD is receiving oxygen. Which nursing action is appropriate?
A. Administer unlimited high-flow oxygen
B. Titrate oxygen according to the prescribed target and clinical condition
, C. Discontinue oxygen if the client becomes dyspneic
D. Avoid monitoring oxygen saturation
Answer: B
Rationale: Oxygen should be carefully titrated to the prescribed target, commonly around 88–
92% for many patients with COPD who are at risk of hypercapnic respiratory failure, depending
on the clinical situation.
10. Which finding is characteristic of emphysema?
A. Productive cough with large amounts of sputum
B. Hyperinflation and decreased breath sounds
C. Massive hemoptysis
D. Sudden unilateral pleuritic pain
Answer: B
Rationale: Emphysema causes destruction of alveolar walls, air trapping, hyperinflation, and
decreased breath sounds.
11. A client with asthma develops severe wheezing followed by markedly decreased breath
sounds. What does this finding indicate?
A. Improvement
B. Severe airflow obstruction
C. Normal asthma progression
D. Resolution of bronchospasm
Answer: B
Rationale: A "silent chest" or markedly diminished breath sounds in severe asthma can indicate
critically reduced airflow and impending respiratory failure.
12. Which medication is commonly used as a rapid-relief bronchodilator for acute asthma
symptoms?
A. Salmeterol
B. Albuterol
