NUR 529 EXAM 2 STUDY GUIDE –
COMPLETE COURSE REVIEW &
PREPARATION RESOURCE
1. A client with Heart Failure is prescribed Furosemide (Lasix) 40 mg IV twice daily. The nurse
should prioritize assessing for which of the following after administration?
A) Hyperkalemia
B) Hypertension
C) Hypokalemia
D) Bradycardia
Answer: C) Hypokalemia
Rationale: Loop diuretics like furosemide cause potassium wasting, leading to hypokalemia. This
is a critical assessment as hypokalemia can precipitate dangerous cardiac dysrhythmias.
2. When teaching a client newly diagnosed with Type 2 Diabetes, the nurse identifies which
statement as indicating a need for further education?
A) "I will rotate the sites where I give my insulin."
B) "I should carry a source of fast-acting sugar with me at all times."
C) "If I feel shaky and sweaty, I should drink a glass of orange juice."
D) "I can skip my medication when I'm not feeling hungry."
Answer: D) "I can skip my medication when I'm not feeling hungry."
Rationale: Diabetes medication is not based on appetite but on maintaining stable blood glucose
levels. Skipping doses can lead to hyperglycemia.
3. A post-operative client suddenly develops dyspnea, tachycardia, and pleuritic chest pain.
The nurse suspects a pulmonary embolism. What is the priority nursing action?
A) Administer Morphine Sulfate as ordered for pain.
B) Place the client in High-Fowler's position and administer oxygen.
C) Draw blood for an arterial blood gas (ABG) analysis.
D) Instruct the client to perform incentive spirometry.
Answer: B) Place the client in High-Fowler's position and administer oxygen.
Rationale: The priority is to promote oxygenation and reduce work of breathing. Administering
oxygen addresses the potential hypoxia while further assessment and treatment are initiated.
4. A client with a history of Myasthenia Gravis is admitted with increased muscle weakness,
difficulty swallowing, and shortness of breath. The nurse should be prepared for which
,primary intervention?
A) Administration of a cholinesterase inhibitor (e.g., Neostigmine).
B) Emergency endotracheal intubation and mechanical ventilation.
C) Administration of IV Immunoglobulin (IVIG).
D) Preparation for a thymectomy.
Answer: B) Emergency endotracheal intubation and mechanical ventilation.
Rationale: This presentation describes a myasthenic crisis, which can lead to respiratory failure
due to muscle paralysis. Securing the airway is the immediate life-saving priority.
5. The nurse is caring for a client with a serum sodium level of 118 mEq/L. Which assessment
finding should the nurse anticipate?
A) Flushed, dry skin and oliguria.
B) Hypertension and bounding pulses.
C) Confusion and generalized seizures.
D) Hyperactive bowel sounds and muscle cramps.
Answer: C) Confusion and generalized seizures.
Rationale: Severe hyponatremia causes cerebral edema, leading to neurological symptoms such
as confusion, lethargy, seizures, and coma.
6. A client with Crohn's disease is started on Infliximab (Remicade). The nurse should teach
the client to report which of the following immediately?
A) Mild headache.
B) Fatigue after infusion.
C) Fever and sore throat.
D) Bruising at the IV site.
Answer: C) Fever and sore throat.
Rationale: TNF-alpha inhibitors like Infliximab increase the risk of serious infections. Fever and
sore throat could indicate an infection that needs prompt medical evaluation.
7. When assessing a client 24 hours after a Total Abdominal Hysterectomy, the nurse is most
concerned about which finding?
A) Pain rated 4/10 along the incision.
B) Scant serosanguinous drainage on the dressing.
C) Absent bowel sounds in all four quadrants.
D) A temperature of 100.9°F (38.3°C).
Answer: D) A temperature of 100.9°F (38.3°C).
*Rationale: While low-grade fever can be expected post-op (atelectasis), a temperature
exceeding 100.5°F (38°C) after the first 24 hours may indicate a developing infection, such as a
wound or urinary tract infection.*
,8. A client with a head injury has clear fluid draining from the nose. Which action should the
nurse take first?
A) Test the fluid with a dextrose stick.
B) Suction the nares to maintain airway patency.
C) Place the client in a semi-Fowler's position.
D) Pack the nose with sterile gauze.
Answer: A) Test the fluid with a dextrose stick.
Rationale: The priority is to determine if the fluid is cerebrospinal fluid (CSF). CSF tests positive
for glucose, while nasal mucus does not. Packing the nose is contraindicated as it can increase
intracranial pressure.
9. The nurse is preparing to administer Lantus (insulin glargine) and Humalog (insulin lispro)
to a client. Which action is correct?
A) Draw up both insulins in the same syringe.
B) Administer the Lantus first, then the Humalog.
C) Administer the Humalog first, then the Lantus.
D) Administer the Lantus subcutaneously and the Humalog intramuscularly.
Answer: C) Administer the Humalog first, then the Lantus.
Rationale: It is standard practice to administer rapid-acting (Humalog) before long-acting
(Lantus) insulin. They should NOT be mixed in the same syringe as Lantus is a cloudy suspension
and its pharmacokinetics would be altered.
10. A client with cirrhosis develops hepatic encephalopathy. The nurse would expect the
provider to order which medication to reduce ammonia levels?
A) Spironolactone (Aldactone).
B) Lactulose (Cephulac).
C) Furosemide (Lasix).
D) Propranolol (Inderal).
Answer: B) Lactulose (Cephulac).
Rationale: Lactulose acidifies the colon, trapping ammonia and facilitating its excretion in the
stool, thereby reducing blood ammonia levels that contribute to encephalopathy.
11. A client with a permanent pacemaker is scheduled for a MRI. What is the nurse's most
appropriate action?
A) Ensure the pacemaker is set to asynchronous mode.
B) Administer a sedative as ordered to prevent anxiety.
C) Inform the radiology department and verify the pacemaker is MRI-compatible.
D) Place a magnet over the pacemaker generator during the procedure.
Answer: C) Inform the radiology department and verify the pacemaker is MRI-compatible.
, Rationale: Traditional pacemakers are a contraindication for MRI. Modern MRI-compatible
pacemakers exist, but this must be verified with the manufacturer's specifications before
proceeding.
12. The nurse is assessing a client with a suspected tension pneumothorax. Which finding is
most characteristic of this condition?
A) Diminished breath sounds on the affected side.
B) Tracheal deviation away from the affected side.
C) Sudden onset of pleuritic chest pain.
D) A cough productive of bloody sputum.
Answer: B) Tracheal deviation away from the affected side.
Rationale: Tension pneumothorax is a medical emergency where air trapped in the pleural space
shifts the mediastinum, causing tracheal deviation. This is a key distinguishing feature.
13. A client with Guillain-Barré syndrome is progressing to the paralytic stage. The nurse's
priority assessment is:
A) Deep tendon reflexes.
B) Forced vital capacity (FVC).
C) Level of consciousness.
D) Pupillary response.
Answer: B) Forced vital capacity (FVC).
Rationale: Guillain-Barré can cause ascending paralysis that affects the respiratory muscles.
Monitoring FVC is critical to anticipate and prevent respiratory failure.
14. Which client is at the highest risk for developing a Deep Vein Thrombosis (DVT)?
A) A 25-year-old postpartum woman who had a normal vaginal delivery.
B) A 45-year-old male with a history of asthma.
C) A 68-year-old obese female who is 1-day post-op from a hip replacement.
D) A 50-year-old male with hypertension controlled by medication.
Answer: C) A 68-year-old obese female who is 1-day post-op from a hip replacement.
Rationale: This client has three major risk factors (Virchow's Triad): advanced age, obesity
(possible hypercoagulability), and post-operative immobility (stasis). Orthopedic surgery of the
lower limbs is a particularly high risk.
15. The nurse is providing discharge teaching for a client prescribed Clopidogrel (Plavix).
Which statement by the client indicates understanding?
A) "I should stop taking this medication one week before any dental procedures."
B) "I will use a soft-bristled toothbrush to reduce gum bleeding."
C) "It is safe for me to take Ibuprofen for a headache."
D) "This medication will help lower my cholesterol."
COMPLETE COURSE REVIEW &
PREPARATION RESOURCE
1. A client with Heart Failure is prescribed Furosemide (Lasix) 40 mg IV twice daily. The nurse
should prioritize assessing for which of the following after administration?
A) Hyperkalemia
B) Hypertension
C) Hypokalemia
D) Bradycardia
Answer: C) Hypokalemia
Rationale: Loop diuretics like furosemide cause potassium wasting, leading to hypokalemia. This
is a critical assessment as hypokalemia can precipitate dangerous cardiac dysrhythmias.
2. When teaching a client newly diagnosed with Type 2 Diabetes, the nurse identifies which
statement as indicating a need for further education?
A) "I will rotate the sites where I give my insulin."
B) "I should carry a source of fast-acting sugar with me at all times."
C) "If I feel shaky and sweaty, I should drink a glass of orange juice."
D) "I can skip my medication when I'm not feeling hungry."
Answer: D) "I can skip my medication when I'm not feeling hungry."
Rationale: Diabetes medication is not based on appetite but on maintaining stable blood glucose
levels. Skipping doses can lead to hyperglycemia.
3. A post-operative client suddenly develops dyspnea, tachycardia, and pleuritic chest pain.
The nurse suspects a pulmonary embolism. What is the priority nursing action?
A) Administer Morphine Sulfate as ordered for pain.
B) Place the client in High-Fowler's position and administer oxygen.
C) Draw blood for an arterial blood gas (ABG) analysis.
D) Instruct the client to perform incentive spirometry.
Answer: B) Place the client in High-Fowler's position and administer oxygen.
Rationale: The priority is to promote oxygenation and reduce work of breathing. Administering
oxygen addresses the potential hypoxia while further assessment and treatment are initiated.
4. A client with a history of Myasthenia Gravis is admitted with increased muscle weakness,
difficulty swallowing, and shortness of breath. The nurse should be prepared for which
,primary intervention?
A) Administration of a cholinesterase inhibitor (e.g., Neostigmine).
B) Emergency endotracheal intubation and mechanical ventilation.
C) Administration of IV Immunoglobulin (IVIG).
D) Preparation for a thymectomy.
Answer: B) Emergency endotracheal intubation and mechanical ventilation.
Rationale: This presentation describes a myasthenic crisis, which can lead to respiratory failure
due to muscle paralysis. Securing the airway is the immediate life-saving priority.
5. The nurse is caring for a client with a serum sodium level of 118 mEq/L. Which assessment
finding should the nurse anticipate?
A) Flushed, dry skin and oliguria.
B) Hypertension and bounding pulses.
C) Confusion and generalized seizures.
D) Hyperactive bowel sounds and muscle cramps.
Answer: C) Confusion and generalized seizures.
Rationale: Severe hyponatremia causes cerebral edema, leading to neurological symptoms such
as confusion, lethargy, seizures, and coma.
6. A client with Crohn's disease is started on Infliximab (Remicade). The nurse should teach
the client to report which of the following immediately?
A) Mild headache.
B) Fatigue after infusion.
C) Fever and sore throat.
D) Bruising at the IV site.
Answer: C) Fever and sore throat.
Rationale: TNF-alpha inhibitors like Infliximab increase the risk of serious infections. Fever and
sore throat could indicate an infection that needs prompt medical evaluation.
7. When assessing a client 24 hours after a Total Abdominal Hysterectomy, the nurse is most
concerned about which finding?
A) Pain rated 4/10 along the incision.
B) Scant serosanguinous drainage on the dressing.
C) Absent bowel sounds in all four quadrants.
D) A temperature of 100.9°F (38.3°C).
Answer: D) A temperature of 100.9°F (38.3°C).
*Rationale: While low-grade fever can be expected post-op (atelectasis), a temperature
exceeding 100.5°F (38°C) after the first 24 hours may indicate a developing infection, such as a
wound or urinary tract infection.*
,8. A client with a head injury has clear fluid draining from the nose. Which action should the
nurse take first?
A) Test the fluid with a dextrose stick.
B) Suction the nares to maintain airway patency.
C) Place the client in a semi-Fowler's position.
D) Pack the nose with sterile gauze.
Answer: A) Test the fluid with a dextrose stick.
Rationale: The priority is to determine if the fluid is cerebrospinal fluid (CSF). CSF tests positive
for glucose, while nasal mucus does not. Packing the nose is contraindicated as it can increase
intracranial pressure.
9. The nurse is preparing to administer Lantus (insulin glargine) and Humalog (insulin lispro)
to a client. Which action is correct?
A) Draw up both insulins in the same syringe.
B) Administer the Lantus first, then the Humalog.
C) Administer the Humalog first, then the Lantus.
D) Administer the Lantus subcutaneously and the Humalog intramuscularly.
Answer: C) Administer the Humalog first, then the Lantus.
Rationale: It is standard practice to administer rapid-acting (Humalog) before long-acting
(Lantus) insulin. They should NOT be mixed in the same syringe as Lantus is a cloudy suspension
and its pharmacokinetics would be altered.
10. A client with cirrhosis develops hepatic encephalopathy. The nurse would expect the
provider to order which medication to reduce ammonia levels?
A) Spironolactone (Aldactone).
B) Lactulose (Cephulac).
C) Furosemide (Lasix).
D) Propranolol (Inderal).
Answer: B) Lactulose (Cephulac).
Rationale: Lactulose acidifies the colon, trapping ammonia and facilitating its excretion in the
stool, thereby reducing blood ammonia levels that contribute to encephalopathy.
11. A client with a permanent pacemaker is scheduled for a MRI. What is the nurse's most
appropriate action?
A) Ensure the pacemaker is set to asynchronous mode.
B) Administer a sedative as ordered to prevent anxiety.
C) Inform the radiology department and verify the pacemaker is MRI-compatible.
D) Place a magnet over the pacemaker generator during the procedure.
Answer: C) Inform the radiology department and verify the pacemaker is MRI-compatible.
, Rationale: Traditional pacemakers are a contraindication for MRI. Modern MRI-compatible
pacemakers exist, but this must be verified with the manufacturer's specifications before
proceeding.
12. The nurse is assessing a client with a suspected tension pneumothorax. Which finding is
most characteristic of this condition?
A) Diminished breath sounds on the affected side.
B) Tracheal deviation away from the affected side.
C) Sudden onset of pleuritic chest pain.
D) A cough productive of bloody sputum.
Answer: B) Tracheal deviation away from the affected side.
Rationale: Tension pneumothorax is a medical emergency where air trapped in the pleural space
shifts the mediastinum, causing tracheal deviation. This is a key distinguishing feature.
13. A client with Guillain-Barré syndrome is progressing to the paralytic stage. The nurse's
priority assessment is:
A) Deep tendon reflexes.
B) Forced vital capacity (FVC).
C) Level of consciousness.
D) Pupillary response.
Answer: B) Forced vital capacity (FVC).
Rationale: Guillain-Barré can cause ascending paralysis that affects the respiratory muscles.
Monitoring FVC is critical to anticipate and prevent respiratory failure.
14. Which client is at the highest risk for developing a Deep Vein Thrombosis (DVT)?
A) A 25-year-old postpartum woman who had a normal vaginal delivery.
B) A 45-year-old male with a history of asthma.
C) A 68-year-old obese female who is 1-day post-op from a hip replacement.
D) A 50-year-old male with hypertension controlled by medication.
Answer: C) A 68-year-old obese female who is 1-day post-op from a hip replacement.
Rationale: This client has three major risk factors (Virchow's Triad): advanced age, obesity
(possible hypercoagulability), and post-operative immobility (stasis). Orthopedic surgery of the
lower limbs is a particularly high risk.
15. The nurse is providing discharge teaching for a client prescribed Clopidogrel (Plavix).
Which statement by the client indicates understanding?
A) "I should stop taking this medication one week before any dental procedures."
B) "I will use a soft-bristled toothbrush to reduce gum bleeding."
C) "It is safe for me to take Ibuprofen for a headache."
D) "This medication will help lower my cholesterol."
