NU131 EXAM / ACTUAL NU131 EXAM 2 LATEST 2026/2027
ACCURATE EXAM COMPLETE REAL QUESTIONS AND
CORRECT VERIFIED ANSWERS WITH DETAILED RATIONALES
(A NEW UPDATED VERSION 2026 EDITION) |GUARANTEED
SUCCESS A+ FULL REVISED NU131 EXAM 2
A nurse is assessing a client who reports acute chest pain. Which finding is most
indicative of a myocardial infarction?
A. Pain relieved by deep breathing
B. Pain described as sharp and localized to one spot
C. Pain radiating to the left arm and jaw
D. Pain increasing with palpation
Correct Answer: C – Pain radiating to the left arm and jaw is a classic sign of
myocardial infarction due to referred pain pathways.
Rationale: Myocardial infarction pain often radiates to the left arm, jaw, or back.
Options A, B, and D are more typical of musculoskeletal or pleuritic pain.
A client with heart failure has jugular vein distention, crackles in the lungs, and
peripheral edema. Which nursing intervention takes priority?
A. Restrict fluids to 1 L per day
B. Administer furosemide as ordered
C. Elevate the legs above heart level
D. Encourage intake of high-sodium foods
Correct Answer: B – Administer furosemide, a loop diuretic, to reduce preload and
relieve fluid overload symptoms.
Rationale: Diuresis reduces pulmonary congestion and edema. Fluid restriction
may follow but is not the first action. Leg elevation worsens venous return. High
sodium is contraindicated.
,A nurse is teaching a client about modifiable risk factors for coronary artery
disease (CAD). Which factor should the nurse include?
A. Age over 65 years
B. Family history of CAD
C. Sedentary lifestyle
D. Male gender
Correct Answer: C – Sedentary lifestyle is a modifiable risk factor.
Rationale: Age, family history, and male gender are nonmodifiable. Physical
inactivity, smoking, hypertension, and hyperlipidemia can be changed.
During a cardiac stress test, the client reports dizziness and becomes pale. The
ECG shows ventricular tachycardia. What is the nurse’s priority action?
A. Stop the test and initiate emergency protocols
B. Slow the treadmill speed and give water
C. Administer sublingual nitroglycerin
D. Increase the test intensity to resolve the rhythm
Correct Answer: A – Stop the test immediately and activate emergency protocols
for potential cardiac arrest.
Rationale: Ventricular tachycardia with symptoms indicates hemodynamic
instability; continued testing is dangerous. Nitroglycerin does not treat this rhythm.
A client post-coronary artery bypass grafting (CABG) has a chest tube drainage of
150 mL/hr for two hours. What should the nurse do first?
A. Clamp the chest tube to prevent further loss
B. Notify the surgeon immediately
C. Document the finding as normal
,D. Milk the tubing to improve drainage
Correct Answer: B – Notify the surgeon immediately because drainage >100
mL/hr suggests hemorrhage.
Rationale: Post-CABG bleeding requires rapid surgical evaluation. Clamping can
cause tension pneumothorax; milking is avoided unless ordered.
Which laboratory value requires immediate intervention in a client with acute
pancreatitis?
A. Serum calcium 9.0 mg/dL
B. Serum glucose 180 mg/dL
C. Serum amylase 300 U/L
D. Serum potassium 5.8 mEq/L
Correct Answer: D – Potassium 5.8 mEq/L is hyperkalemia, which can cause
cardiac arrhythmias.
*Rationale: Hyperkalemia is life-threatening. Elevated amylase and glucose are
expected in pancreatitis; calcium may drop but 9.0 is normal.*
A nurse is providing dietary teaching for a client with gastroesophageal reflux
disease (GERD). Which statement indicates understanding?
A. "I will lie down for 30 minutes after eating."
B. "I can have coffee as long as it is decaf."
C. "I should eat small, frequent meals."
D. "Tomato sauce is fine if I take an antacid."
Correct Answer: C – Small, frequent meals reduce gastric distension and reflux.
Rationale: Lying down worsens reflux; caffeine and acidic foods like tomato
increase symptoms regardless of antacids.
, A client with cirrhosis develops asterixis. What intervention should the nurse
anticipate?
A. High-protein diet
B. Lactulose administration
C. Paracentesis
D. Vitamin K injection
Correct Answer: B – Lactulose reduces serum ammonia levels, treating hepatic
encephalopathy manifested by asterixis.
Rationale: Asterixis (liver flap) indicates ammonia accumulation. High-protein diet
worsens it. Paracentesis treats ascites; vitamin K treats coagulopathy.
A client presents with sudden severe abdominal pain, nausea, and vomiting. The
abdomen is board-like and rigid. What is the priority nursing action?
A. Administer oral pain medication
B. Apply a heating pad to the abdomen
C. Prepare the client for emergency surgery
D. Encourage oral fluids
Correct Answer: C – Prepare for emergency surgery due to suspected perforated
viscus.
Rationale: Board-like rigidity suggests peritonitis from perforation. NPO, IV
fluids, and surgery are needed. Pain meds may mask symptoms; heat and oral
fluids are contraindicated.
A nurse is caring for a client receiving total parenteral nutrition (TPN). Which
complication requires immediate intervention?
A. Blood glucose 140 mg/dL
B. Weight gain of 0.5 kg in 24 hours
C. Temperature 38.9°C (102°F)
ACCURATE EXAM COMPLETE REAL QUESTIONS AND
CORRECT VERIFIED ANSWERS WITH DETAILED RATIONALES
(A NEW UPDATED VERSION 2026 EDITION) |GUARANTEED
SUCCESS A+ FULL REVISED NU131 EXAM 2
A nurse is assessing a client who reports acute chest pain. Which finding is most
indicative of a myocardial infarction?
A. Pain relieved by deep breathing
B. Pain described as sharp and localized to one spot
C. Pain radiating to the left arm and jaw
D. Pain increasing with palpation
Correct Answer: C – Pain radiating to the left arm and jaw is a classic sign of
myocardial infarction due to referred pain pathways.
Rationale: Myocardial infarction pain often radiates to the left arm, jaw, or back.
Options A, B, and D are more typical of musculoskeletal or pleuritic pain.
A client with heart failure has jugular vein distention, crackles in the lungs, and
peripheral edema. Which nursing intervention takes priority?
A. Restrict fluids to 1 L per day
B. Administer furosemide as ordered
C. Elevate the legs above heart level
D. Encourage intake of high-sodium foods
Correct Answer: B – Administer furosemide, a loop diuretic, to reduce preload and
relieve fluid overload symptoms.
Rationale: Diuresis reduces pulmonary congestion and edema. Fluid restriction
may follow but is not the first action. Leg elevation worsens venous return. High
sodium is contraindicated.
,A nurse is teaching a client about modifiable risk factors for coronary artery
disease (CAD). Which factor should the nurse include?
A. Age over 65 years
B. Family history of CAD
C. Sedentary lifestyle
D. Male gender
Correct Answer: C – Sedentary lifestyle is a modifiable risk factor.
Rationale: Age, family history, and male gender are nonmodifiable. Physical
inactivity, smoking, hypertension, and hyperlipidemia can be changed.
During a cardiac stress test, the client reports dizziness and becomes pale. The
ECG shows ventricular tachycardia. What is the nurse’s priority action?
A. Stop the test and initiate emergency protocols
B. Slow the treadmill speed and give water
C. Administer sublingual nitroglycerin
D. Increase the test intensity to resolve the rhythm
Correct Answer: A – Stop the test immediately and activate emergency protocols
for potential cardiac arrest.
Rationale: Ventricular tachycardia with symptoms indicates hemodynamic
instability; continued testing is dangerous. Nitroglycerin does not treat this rhythm.
A client post-coronary artery bypass grafting (CABG) has a chest tube drainage of
150 mL/hr for two hours. What should the nurse do first?
A. Clamp the chest tube to prevent further loss
B. Notify the surgeon immediately
C. Document the finding as normal
,D. Milk the tubing to improve drainage
Correct Answer: B – Notify the surgeon immediately because drainage >100
mL/hr suggests hemorrhage.
Rationale: Post-CABG bleeding requires rapid surgical evaluation. Clamping can
cause tension pneumothorax; milking is avoided unless ordered.
Which laboratory value requires immediate intervention in a client with acute
pancreatitis?
A. Serum calcium 9.0 mg/dL
B. Serum glucose 180 mg/dL
C. Serum amylase 300 U/L
D. Serum potassium 5.8 mEq/L
Correct Answer: D – Potassium 5.8 mEq/L is hyperkalemia, which can cause
cardiac arrhythmias.
*Rationale: Hyperkalemia is life-threatening. Elevated amylase and glucose are
expected in pancreatitis; calcium may drop but 9.0 is normal.*
A nurse is providing dietary teaching for a client with gastroesophageal reflux
disease (GERD). Which statement indicates understanding?
A. "I will lie down for 30 minutes after eating."
B. "I can have coffee as long as it is decaf."
C. "I should eat small, frequent meals."
D. "Tomato sauce is fine if I take an antacid."
Correct Answer: C – Small, frequent meals reduce gastric distension and reflux.
Rationale: Lying down worsens reflux; caffeine and acidic foods like tomato
increase symptoms regardless of antacids.
, A client with cirrhosis develops asterixis. What intervention should the nurse
anticipate?
A. High-protein diet
B. Lactulose administration
C. Paracentesis
D. Vitamin K injection
Correct Answer: B – Lactulose reduces serum ammonia levels, treating hepatic
encephalopathy manifested by asterixis.
Rationale: Asterixis (liver flap) indicates ammonia accumulation. High-protein diet
worsens it. Paracentesis treats ascites; vitamin K treats coagulopathy.
A client presents with sudden severe abdominal pain, nausea, and vomiting. The
abdomen is board-like and rigid. What is the priority nursing action?
A. Administer oral pain medication
B. Apply a heating pad to the abdomen
C. Prepare the client for emergency surgery
D. Encourage oral fluids
Correct Answer: C – Prepare for emergency surgery due to suspected perforated
viscus.
Rationale: Board-like rigidity suggests peritonitis from perforation. NPO, IV
fluids, and surgery are needed. Pain meds may mask symptoms; heat and oral
fluids are contraindicated.
A nurse is caring for a client receiving total parenteral nutrition (TPN). Which
complication requires immediate intervention?
A. Blood glucose 140 mg/dL
B. Weight gain of 0.5 kg in 24 hours
C. Temperature 38.9°C (102°F)
