NU180 | NU180 Nursing and Healthcare II | NCLEX
Style Exam 1 v1 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A nurse is assessing a client with chronic heart failure. Which finding should the
nurse report to the provider immediately?
A. A weight gain of 3 pounds in 24 hours
B. Pitting edema +1 in the lower extremities
C. Fatigue after performing activities of daily living
D. Occasional dry cough at night
Correct Answer: A
Expert Explanation: A rapid weight gain is a primary indicator of worsening fluid
volume overload in heart failure patients. This assessment finding suggests that the
patient is retaining fluid, which can quickly lead to pulmonary edema. The nurse
must notify the provider to adjust diuretic therapy or other treatments to prevent
further decompensation.
2. A client is prescribed lisinopril for hypertension. Which side effect should the nurse
instruct the client to report specifically?
A. Increased urinary frequency
B. Occasional dizziness when standing
,C. Persistent dry cough
D. Mild headache in the morning
Correct Answer: C
Expert Explanation: A persistent dry cough is a common and specific side effect of
ACE inhibitors like lisinopril. This occurs because the medication causes an
accumulation of bradykinin in the lungs. If this symptom occurs, the provider may
need to switch the client to an angiotensin II receptor blocker (ARB) to improve
compliance.
3. The nurse is caring for a client with a history of COPD who is receiving oxygen via
nasal cannula. Which oxygen flow rate should the nurse maintain?
A. 1 to 2 L/min
B. 5 to 6 L/min
C. 8 to 10 L/min
D. 12 to 15 L/min
Correct Answer: A
Expert Explanation: Patients with COPD often rely on a hypoxic drive to breathe
rather than high CO2 levels. Providing high concentrations of oxygen can suppress
this respiratory drive, potentially leading to respiratory arrest. Therefore, low-flow
,oxygen therapy is strictly maintained to ensure safety and adequate oxygenation
without suppressing the drive to breathe.
4. Which laboratory value is the priority for a nurse to monitor in a client receiving
furosemide?
A. Sodium level
B. Potassium level
C. Calcium level
D. Magnesium level
Correct Answer: B
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of
potassium along with water and sodium. Hypokalemia is a life-threatening
complication that can lead to cardiac arrhythmias and muscle weakness. The nurse
must monitor potassium levels closely and may anticipate the need for potassium
supplements or increased dietary intake.
5. An older adult client is admitted with dehydration. Which assessment finding is the
most reliable indicator of fluid volume status in this population?
A. Skin turgor on the back of the hand
B. Skin turgor on the forehead or sternum
, C. Presence of a coating on the tongue
D. Moisture level of the oral mucosa
Correct Answer: B
Expert Explanation: Skin turgor on the back of the hand is often unreliable in older
adults due to the loss of skin elasticity associated with aging. Checking turgor over
the sternum or forehead provides a more accurate assessment of hydration status. If
the skin remains tented in these areas, it is a strong indicator of significant fluid
volume deficit.
6. A nurse is preparing to administer digoxin to a client with atrial fibrillation. What
action should the nurse take first?
A. Assess the client’s blood pressure
B. Ask the client if they have any blurred vision
C. Check the latest serum creatinine level
D. Measure the apical pulse for 60 seconds
Correct Answer: D
Expert Explanation: Digoxin decreases the heart rate by slowing conduction
through the AV node. The nurse must assess the apical pulse for a full minute to
ensure it is above 60 beats per minute before administration. If the pulse is below
Style Exam 1 v1 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A nurse is assessing a client with chronic heart failure. Which finding should the
nurse report to the provider immediately?
A. A weight gain of 3 pounds in 24 hours
B. Pitting edema +1 in the lower extremities
C. Fatigue after performing activities of daily living
D. Occasional dry cough at night
Correct Answer: A
Expert Explanation: A rapid weight gain is a primary indicator of worsening fluid
volume overload in heart failure patients. This assessment finding suggests that the
patient is retaining fluid, which can quickly lead to pulmonary edema. The nurse
must notify the provider to adjust diuretic therapy or other treatments to prevent
further decompensation.
2. A client is prescribed lisinopril for hypertension. Which side effect should the nurse
instruct the client to report specifically?
A. Increased urinary frequency
B. Occasional dizziness when standing
,C. Persistent dry cough
D. Mild headache in the morning
Correct Answer: C
Expert Explanation: A persistent dry cough is a common and specific side effect of
ACE inhibitors like lisinopril. This occurs because the medication causes an
accumulation of bradykinin in the lungs. If this symptom occurs, the provider may
need to switch the client to an angiotensin II receptor blocker (ARB) to improve
compliance.
3. The nurse is caring for a client with a history of COPD who is receiving oxygen via
nasal cannula. Which oxygen flow rate should the nurse maintain?
A. 1 to 2 L/min
B. 5 to 6 L/min
C. 8 to 10 L/min
D. 12 to 15 L/min
Correct Answer: A
Expert Explanation: Patients with COPD often rely on a hypoxic drive to breathe
rather than high CO2 levels. Providing high concentrations of oxygen can suppress
this respiratory drive, potentially leading to respiratory arrest. Therefore, low-flow
,oxygen therapy is strictly maintained to ensure safety and adequate oxygenation
without suppressing the drive to breathe.
4. Which laboratory value is the priority for a nurse to monitor in a client receiving
furosemide?
A. Sodium level
B. Potassium level
C. Calcium level
D. Magnesium level
Correct Answer: B
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of
potassium along with water and sodium. Hypokalemia is a life-threatening
complication that can lead to cardiac arrhythmias and muscle weakness. The nurse
must monitor potassium levels closely and may anticipate the need for potassium
supplements or increased dietary intake.
5. An older adult client is admitted with dehydration. Which assessment finding is the
most reliable indicator of fluid volume status in this population?
A. Skin turgor on the back of the hand
B. Skin turgor on the forehead or sternum
, C. Presence of a coating on the tongue
D. Moisture level of the oral mucosa
Correct Answer: B
Expert Explanation: Skin turgor on the back of the hand is often unreliable in older
adults due to the loss of skin elasticity associated with aging. Checking turgor over
the sternum or forehead provides a more accurate assessment of hydration status. If
the skin remains tented in these areas, it is a strong indicator of significant fluid
volume deficit.
6. A nurse is preparing to administer digoxin to a client with atrial fibrillation. What
action should the nurse take first?
A. Assess the client’s blood pressure
B. Ask the client if they have any blurred vision
C. Check the latest serum creatinine level
D. Measure the apical pulse for 60 seconds
Correct Answer: D
Expert Explanation: Digoxin decreases the heart rate by slowing conduction
through the AV node. The nurse must assess the apical pulse for a full minute to
ensure it is above 60 beats per minute before administration. If the pulse is below
