NUR 233 EXAM 2 – Hondros College
Answer Key & Rationales Included
Graded A+ (2026 Edition)
Question 1
A nurse is caring for a client with heart failure who has crackles in the lung bases and an SaO₂ of 88%.
Which intervention should the nurse implement first?
A. Raise the head of the bed to 45 degrees
B. Administer furosemide IV push
C. Apply a non-rebreather mask at 15 L/min
D. Notify the healthcare provider
Correct Answer: A
Rationale:
A – Correct: Raising the HOB reduces venous return, decreases preload, and improves lung expansion,
addressing both crackles and oxygenation immediately.
B – Incorrect: Furosemide will reduce fluid overload but takes time to work; not the first action.
C – Incorrect: Oxygen may be needed but positioning comes first to optimize ventilation.
D – Incorrect: Notification can follow after immediate interventions.
,Question 2
A postoperative client reports sudden chest pain and dyspnea. The nurse notes tachycardia and
hypotension. Which condition should the nurse suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Pneumothorax
D. Wound dehiscence
Correct Answer: B
Rationale:
A – Incorrect: Atelectasis usually causes low-grade fever and crackles, not sudden hypotension.
B – Correct: Postop sudden chest pain, dyspnea, tachycardia, hypotension are classic signs of pulmonary
embolism.
C – Incorrect: Pneumothorax presents with absent breath sounds and tracheal deviation.
D – Incorrect: Dehiscence involves wound separation, not sudden chest pain/dyspnea.
Question 3
A client with chronic kidney disease has a potassium level of 6.8 mEq/L. Which assessment finding is
most concerning?
A. Blood pressure 148/90
B. Urine output 30 mL/hr
C. Tall peaked T waves on ECG
D. Serum creatinine 3.5 mg/dL
Correct Answer: C
,Rationale:
A – Incorrect: Hypertension is common but not immediately life-threatening.
B – Incorrect: Urine output is low but not as urgent as dysrhythmia risk.
C – Correct: Tall peaked T waves indicate hyperkalemia and risk for cardiac arrest.
D – Incorrect: Creatinine reflects kidney function but doesn’t require emergent treatment.
Question 4
A nurse is teaching a client with diabetes about foot care. Which statement indicates a need for further
teaching?
A. “I will soak my feet daily in warm water for 30 minutes.”
B. “I will check inside my shoes before putting them on.”
C. “I will dry between my toes after bathing.”
D. “I will wear white cotton socks.”
Correct Answer: A
Rationale:
A – Correct (needs teaching): Prolonged soaking macerates skin and increases infection risk.
B – Incorrect: Checking shoes prevents injury from objects.
C – Incorrect: Drying between toes prevents fungal growth.
D – Incorrect: White socks allow visualization of drainage.
, Question 5
A client receiving a blood transfusion develops chills, fever, and lower back pain. What is the priority
action?
A. Slow the transfusion rate
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain a urine sample
Correct Answer: B
Rationale:
A – Incorrect: Slowing does not stop a possible hemolytic reaction.
B – Correct: Stop transfusion immediately, then notify provider.
C – Incorrect: Treat symptoms after stopping the transfusion.
D – Incorrect: Urine sample is needed later for hemoglobinuria.
Question 6
A client on a ventilator has an endotracheal tube. Which finding indicates a possible displacement of the
tube into the right main bronchus?
A. Equal breath sounds bilaterally
B. Diminished breath sounds on the left
C. Subcutaneous emphysema
D. Gastric distention
Correct Answer: B
Rationale:
Answer Key & Rationales Included
Graded A+ (2026 Edition)
Question 1
A nurse is caring for a client with heart failure who has crackles in the lung bases and an SaO₂ of 88%.
Which intervention should the nurse implement first?
A. Raise the head of the bed to 45 degrees
B. Administer furosemide IV push
C. Apply a non-rebreather mask at 15 L/min
D. Notify the healthcare provider
Correct Answer: A
Rationale:
A – Correct: Raising the HOB reduces venous return, decreases preload, and improves lung expansion,
addressing both crackles and oxygenation immediately.
B – Incorrect: Furosemide will reduce fluid overload but takes time to work; not the first action.
C – Incorrect: Oxygen may be needed but positioning comes first to optimize ventilation.
D – Incorrect: Notification can follow after immediate interventions.
,Question 2
A postoperative client reports sudden chest pain and dyspnea. The nurse notes tachycardia and
hypotension. Which condition should the nurse suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Pneumothorax
D. Wound dehiscence
Correct Answer: B
Rationale:
A – Incorrect: Atelectasis usually causes low-grade fever and crackles, not sudden hypotension.
B – Correct: Postop sudden chest pain, dyspnea, tachycardia, hypotension are classic signs of pulmonary
embolism.
C – Incorrect: Pneumothorax presents with absent breath sounds and tracheal deviation.
D – Incorrect: Dehiscence involves wound separation, not sudden chest pain/dyspnea.
Question 3
A client with chronic kidney disease has a potassium level of 6.8 mEq/L. Which assessment finding is
most concerning?
A. Blood pressure 148/90
B. Urine output 30 mL/hr
C. Tall peaked T waves on ECG
D. Serum creatinine 3.5 mg/dL
Correct Answer: C
,Rationale:
A – Incorrect: Hypertension is common but not immediately life-threatening.
B – Incorrect: Urine output is low but not as urgent as dysrhythmia risk.
C – Correct: Tall peaked T waves indicate hyperkalemia and risk for cardiac arrest.
D – Incorrect: Creatinine reflects kidney function but doesn’t require emergent treatment.
Question 4
A nurse is teaching a client with diabetes about foot care. Which statement indicates a need for further
teaching?
A. “I will soak my feet daily in warm water for 30 minutes.”
B. “I will check inside my shoes before putting them on.”
C. “I will dry between my toes after bathing.”
D. “I will wear white cotton socks.”
Correct Answer: A
Rationale:
A – Correct (needs teaching): Prolonged soaking macerates skin and increases infection risk.
B – Incorrect: Checking shoes prevents injury from objects.
C – Incorrect: Drying between toes prevents fungal growth.
D – Incorrect: White socks allow visualization of drainage.
, Question 5
A client receiving a blood transfusion develops chills, fever, and lower back pain. What is the priority
action?
A. Slow the transfusion rate
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain a urine sample
Correct Answer: B
Rationale:
A – Incorrect: Slowing does not stop a possible hemolytic reaction.
B – Correct: Stop transfusion immediately, then notify provider.
C – Incorrect: Treat symptoms after stopping the transfusion.
D – Incorrect: Urine sample is needed later for hemoglobinuria.
Question 6
A client on a ventilator has an endotracheal tube. Which finding indicates a possible displacement of the
tube into the right main bronchus?
A. Equal breath sounds bilaterally
B. Diminished breath sounds on the left
C. Subcutaneous emphysema
D. Gastric distention
Correct Answer: B
Rationale:
