Mastering NURS 231 Finals: Your Ultimate Guide to A+ Success with
Actual Exam Questions and Answers (Versions A & B).
A Fully Certified Exam Study Guide Current Updated Edition
2025/2026
"critical rescue" assessment criteria for patients experiencing stroke/TBI to detect increased
intracranial pressure and/or hypertension -ans *ABC's are priority (w/in 10 minutes); Neuro
assessment , LOC/cognition, GCS, call rapid response
Early signs:
-headache
-N/V
-blurry vision/visual disturbances
-SOB
-seizures (also late)
-chest pressure
-change LOC
Late:
-elevated BP
-bradycardia
-cerebral vasodilation
-seizures
-cushings triad
-increased systolic, widened pulse pressure
-irregular resp
1. The student nurse studying shock understands that the common manifestations of this
condition are directly related to which problems? (Select all that apply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
d. Impaired renal perfusion
e. Increased perfusion -ans a. Anaerobic metabolism
c. Hypotension
The common manifestations of shock, no matter the cause, are directly related to the effects
of anaerobic
metabolism and hypotension. Hyperglycemia, impaired renal function, and increased
perfusion are not
manifestations of shock.
1) What is the formula for MAP?
2) What's the normal?
3) What is pts MAP that has BP of 120/80?
4) What is the pts MAP that has BP of 100/65 -ans 1) MAP= (2xDBP)+SBP / 3
2) normal is 70-110, but trend!
3) 93
4) 76
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is
best?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
,Mastering NURS 231 Finals: Your Ultimate Guide to A+ Success with
Actual Exam Questions and Answers (Versions A & B).
A Fully Certified Exam Study Guide Current Updated Edition
2025/2026
c. Obtain a new oximeter from central
supply.
d. Tell the client to take slow, deep breath -ans a. Assess for other manifestations of hypoxia.
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors
can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse
should conduct a more thorough assessment. The other actions are not appropriate for a
hypoxic client.
A client arrives in the emergency department after being in a car crash with fatalities. The
client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes
priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters. -ans ANS: B
Airway is the priority, followed by breathing and circulation (IVs and direct pressure).
Obtaining consent is done by the physician.
A client comes to the emergency department with chest discomfort. Which action does the
nurse perform first?
a) Provides pain relief medication
b) Remains calm and stays with the client
c) Obtains the client's description of the chest discomfort
d) Administers oxygen therapy -ans c) Obtains the client's description of the chest discomfort
*Neither oxygen therapy nor pain medication is the first priority in this situation. An
assessment is needed first.
A client had an acute myocardial infarction. What assessment finding indicates to the nurse
that a significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours -ans c. Poor peripheral pulses and cool skin
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and
should be reported
immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of
94% is just
slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.
A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac
rhythm as sinus bradycardia. What action by the nurse is most important?
a. Assess the clients blood pressure and level of consciousness.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication. -ans ANS: A
,Mastering NURS 231 Finals: Your Ultimate Guide to A+ Success with
Actual Exam Questions and Answers (Versions A & B).
A Fully Certified Exam Study Guide Current Updated Edition
2025/2026
Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased
perfusion, as seen in
this ECG strip showing sinus bradycardia. The nurse should first assess the clients
hemodynamic status,
including vital signs and level of consciousness. The client may or may not need the Rapid
Response Team, a
temporary pacemaker, or medication; there is no indication of this in the question.
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the
clients oxygen
saturation has not significantly improved. What response by the nurse is best?
a. Breathing so rapidly interferes with oxygenation.
b. Maybe the client has respiratory distress syndrome.
c. The blood clot interferes with perfusion in the lungs.
d. The client needs immediate intubation and mechanical
ventilation. -ans c. The blood clot interferes with perfusion in the lungs.
*A large blood clot in the lungs will significantly impair gas exchange and oxygenation.
Unless the clot is
dissolved, this process will continue unabated. Hyperventilation can interfere with
oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating,
and this is also not the most precise physiologic answer. Respiratory distress syndrome can
occur, but this is not as likely. The client may need to be mechanically ventilated, but without
concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
A client has been brought to the emergency department with a life-threatening chest injury.
What action by
the nurse takes priority?
a. Apply oxygen at 100%.
b. Assess the respiratory rate.
c. Ensure a patent airway.
d. Start two large-bore IV lines. -ans c. Ensure a patent airway.
*The priority for any chest trauma client is airway, breathing, circulation. The nurse first
ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are
next, followed by inserting IVs.
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping
blood pressure. What medication should the nurse anticipate the client will need as the
priority?
a. Alteplase (tpA)
b. Enoxaparin (Lovenox)
c. Unfractionated heparin
d. Warfarin sodium (Coumadin) -ans a. Alteplase (tpA)
*Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic
instability. The nurse knows this drug is the priority, although heparin may be started
initially. Enoxaparin and warfarin are not indicated in this setting.
, Mastering NURS 231 Finals: Your Ultimate Guide to A+ Success with
Actual Exam Questions and Answers (Versions A & B).
A Fully Certified Exam Study Guide Current Updated Edition
2025/2026
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse
notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure
dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain. -ans ANS: B
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from
the insertion site. Since these vital signs are out of the normal range, are a change, and are
consistent with blood loss, the nurse should assess the client for any bleeding associated with
the arterial line. The nurse should document the findings after a full assessment. The client
may or may not need pain medication and rest; the nurse first needs to rule out any emergent
bleeding.
A client in ICU who is receiving mechanical ventilation begins to pick at the bedcovers.
Which action will the nurse take next?
a) Request that the family leave to decrease the client's agitation.
b) Assess for adequate oxygenation.
c) Explain that the tube in the client's throat helps with breathing.
d) Increase the sedation. -ans b) Assess for adequate oxygenation.
*Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia.
Increasing sedation is not indicated for this pt and may mask symptoms such as hypoxemia or
worsening respiratory failure.
A client in shock has been started on dopamine. What assessment finding requires the nurse
to
communicate with the provider immediately?
a. Blood pressure of 98/68 mm Hg
b. Pedal pulses 1+/4+ bilaterally
c. Report of chest heaviness
d. Urine output of 32 mL/hr -ans c. Report of chest heaviness
*Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of
dopamine. While taking
dopamine, the oxygen requirements of the heart are increased due to increased myocardial
workload, and may cause ischemia. Without knowing the clients previous blood pressure or
pedal pulses, there is not enough information to determine if these are an improvement or not.
A urine output of 32 mL/hr is acceptable.
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by
nausea and vomiting. What action by the nurse takes priority?
a. Administer an aspirin.
b. Call for an electrocardiogram (ECG).
c. Maintain airway patency.
d. Notify the provider. -ans ANS: C
Airway always is the priority. The other actions are important in this situation as well, but the
nurse should stay with the client and ensure the airway remains patent (especially if vomiting
Actual Exam Questions and Answers (Versions A & B).
A Fully Certified Exam Study Guide Current Updated Edition
2025/2026
"critical rescue" assessment criteria for patients experiencing stroke/TBI to detect increased
intracranial pressure and/or hypertension -ans *ABC's are priority (w/in 10 minutes); Neuro
assessment , LOC/cognition, GCS, call rapid response
Early signs:
-headache
-N/V
-blurry vision/visual disturbances
-SOB
-seizures (also late)
-chest pressure
-change LOC
Late:
-elevated BP
-bradycardia
-cerebral vasodilation
-seizures
-cushings triad
-increased systolic, widened pulse pressure
-irregular resp
1. The student nurse studying shock understands that the common manifestations of this
condition are directly related to which problems? (Select all that apply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
d. Impaired renal perfusion
e. Increased perfusion -ans a. Anaerobic metabolism
c. Hypotension
The common manifestations of shock, no matter the cause, are directly related to the effects
of anaerobic
metabolism and hypotension. Hyperglycemia, impaired renal function, and increased
perfusion are not
manifestations of shock.
1) What is the formula for MAP?
2) What's the normal?
3) What is pts MAP that has BP of 120/80?
4) What is the pts MAP that has BP of 100/65 -ans 1) MAP= (2xDBP)+SBP / 3
2) normal is 70-110, but trend!
3) 93
4) 76
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is
best?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
,Mastering NURS 231 Finals: Your Ultimate Guide to A+ Success with
Actual Exam Questions and Answers (Versions A & B).
A Fully Certified Exam Study Guide Current Updated Edition
2025/2026
c. Obtain a new oximeter from central
supply.
d. Tell the client to take slow, deep breath -ans a. Assess for other manifestations of hypoxia.
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors
can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse
should conduct a more thorough assessment. The other actions are not appropriate for a
hypoxic client.
A client arrives in the emergency department after being in a car crash with fatalities. The
client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes
priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters. -ans ANS: B
Airway is the priority, followed by breathing and circulation (IVs and direct pressure).
Obtaining consent is done by the physician.
A client comes to the emergency department with chest discomfort. Which action does the
nurse perform first?
a) Provides pain relief medication
b) Remains calm and stays with the client
c) Obtains the client's description of the chest discomfort
d) Administers oxygen therapy -ans c) Obtains the client's description of the chest discomfort
*Neither oxygen therapy nor pain medication is the first priority in this situation. An
assessment is needed first.
A client had an acute myocardial infarction. What assessment finding indicates to the nurse
that a significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours -ans c. Poor peripheral pulses and cool skin
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and
should be reported
immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of
94% is just
slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.
A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac
rhythm as sinus bradycardia. What action by the nurse is most important?
a. Assess the clients blood pressure and level of consciousness.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication. -ans ANS: A
,Mastering NURS 231 Finals: Your Ultimate Guide to A+ Success with
Actual Exam Questions and Answers (Versions A & B).
A Fully Certified Exam Study Guide Current Updated Edition
2025/2026
Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased
perfusion, as seen in
this ECG strip showing sinus bradycardia. The nurse should first assess the clients
hemodynamic status,
including vital signs and level of consciousness. The client may or may not need the Rapid
Response Team, a
temporary pacemaker, or medication; there is no indication of this in the question.
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the
clients oxygen
saturation has not significantly improved. What response by the nurse is best?
a. Breathing so rapidly interferes with oxygenation.
b. Maybe the client has respiratory distress syndrome.
c. The blood clot interferes with perfusion in the lungs.
d. The client needs immediate intubation and mechanical
ventilation. -ans c. The blood clot interferes with perfusion in the lungs.
*A large blood clot in the lungs will significantly impair gas exchange and oxygenation.
Unless the clot is
dissolved, this process will continue unabated. Hyperventilation can interfere with
oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating,
and this is also not the most precise physiologic answer. Respiratory distress syndrome can
occur, but this is not as likely. The client may need to be mechanically ventilated, but without
concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
A client has been brought to the emergency department with a life-threatening chest injury.
What action by
the nurse takes priority?
a. Apply oxygen at 100%.
b. Assess the respiratory rate.
c. Ensure a patent airway.
d. Start two large-bore IV lines. -ans c. Ensure a patent airway.
*The priority for any chest trauma client is airway, breathing, circulation. The nurse first
ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are
next, followed by inserting IVs.
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping
blood pressure. What medication should the nurse anticipate the client will need as the
priority?
a. Alteplase (tpA)
b. Enoxaparin (Lovenox)
c. Unfractionated heparin
d. Warfarin sodium (Coumadin) -ans a. Alteplase (tpA)
*Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic
instability. The nurse knows this drug is the priority, although heparin may be started
initially. Enoxaparin and warfarin are not indicated in this setting.
, Mastering NURS 231 Finals: Your Ultimate Guide to A+ Success with
Actual Exam Questions and Answers (Versions A & B).
A Fully Certified Exam Study Guide Current Updated Edition
2025/2026
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse
notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure
dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain. -ans ANS: B
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from
the insertion site. Since these vital signs are out of the normal range, are a change, and are
consistent with blood loss, the nurse should assess the client for any bleeding associated with
the arterial line. The nurse should document the findings after a full assessment. The client
may or may not need pain medication and rest; the nurse first needs to rule out any emergent
bleeding.
A client in ICU who is receiving mechanical ventilation begins to pick at the bedcovers.
Which action will the nurse take next?
a) Request that the family leave to decrease the client's agitation.
b) Assess for adequate oxygenation.
c) Explain that the tube in the client's throat helps with breathing.
d) Increase the sedation. -ans b) Assess for adequate oxygenation.
*Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia.
Increasing sedation is not indicated for this pt and may mask symptoms such as hypoxemia or
worsening respiratory failure.
A client in shock has been started on dopamine. What assessment finding requires the nurse
to
communicate with the provider immediately?
a. Blood pressure of 98/68 mm Hg
b. Pedal pulses 1+/4+ bilaterally
c. Report of chest heaviness
d. Urine output of 32 mL/hr -ans c. Report of chest heaviness
*Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of
dopamine. While taking
dopamine, the oxygen requirements of the heart are increased due to increased myocardial
workload, and may cause ischemia. Without knowing the clients previous blood pressure or
pedal pulses, there is not enough information to determine if these are an improvement or not.
A urine output of 32 mL/hr is acceptable.
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by
nausea and vomiting. What action by the nurse takes priority?
a. Administer an aspirin.
b. Call for an electrocardiogram (ECG).
c. Maintain airway patency.
d. Notify the provider. -ans ANS: C
Airway always is the priority. The other actions are important in this situation as well, but the
nurse should stay with the client and ensure the airway remains patent (especially if vomiting
