NUR 425 FINAL EXAM NEWEST COMPLETE 200+
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+|
Question 1
A nurse is caring for a client admitted with acute decompensated heart
failure. The client has a new prescription for an intravenous loop diuretic
(e.g., furosemide). Which of the following should the nurse monitor most
closely?
A) Serum sodium and chloride levels.
B) Blood pressure, urine output, and serum potassium.
C) Serum calcium and magnesium levels.
D) Blood glucose levels.
E) Liver function tests.
Correct Answer: B) Blood pressure, urine output, and serum
potassium.
Rationale: Loop diuretics rapidly remove fluid, causing a decrease in
blood pressure and increased urine output. They also lead to
significant potassium excretion, so hypokalemia is a major risk
requiring close monitoring.
Question 2
A client with a history of hypertension and diabetes is admitted with acute
pancreatitis. The nurse should anticipate monitoring for which of the
following complications?
A) Right upper quadrant pain radiating to the right shoulder.
B) Hyperglycemia, hypocalcemia, and acute respiratory distress syndrome
(ARDS).
C) Hypokalemia and metabolic alkalosis.
D) Jaundice with dark urine.
E) Left lower quadrant tenderness.
Correct Answer: B) Hyperglycemia, hypocalcemia, and acute
respiratory distress syndrome (ARDS).
Rationale: Acute pancreatitis can lead to hyperglycemia (pancreatic
,dysfunction), hypocalcemia (fat necrosis consuming calcium), and
can trigger a severe systemic inflammatory response, potentially
leading to ARDS.
Question 3
A nurse is caring for a client admitted with an acute ST-segment elevation
myocardial infarction (STEMI). The client has a new prescription for
metoprolol. The nurse should withhold the medication and notify the provider
if the client exhibits which of the following?
A) Heart rate of 80/min.
B) Blood pressure of 130/80 mmHg.
C) New onset of wheezing.
D) Mild peripheral edema.
E) Chest pain rated 4/10.
Correct Answer: C) New onset of wheezing.
Rationale: Metoprolol is a beta-blocker. New onset wheezing could
indicate bronchospasm, particularly in clients with reactive airway
disease (asthma, COPD), which is a contraindication or requires
caution with beta-blockers.
Question 4
A client is admitted to the intensive care unit following a cerebral aneurysm
rupture and subarachnoid hemorrhage. The nurse should prioritize
monitoring for which of the following neurological complications?
A) Gradual decrease in blood pressure.
B) Stable neurological assessment findings.
C) Re-bleeding, cerebral vasospasm, and increased intracranial pressure
(ICP).
D) Increased urine output.
E) Peripheral edema.
Correct Answer: C) Re-bleeding, cerebral vasospasm, and increased
intracranial pressure (ICP).
,Rationale: Re-bleeding (re-rupture) and cerebral vasospasm
(narrowing of cerebral blood vessels, typically 3-14 days post-SAH)
are critical and potentially devastating complications. Increased ICP
is a constant threat.
Question 5
A nurse is assessing a client who is diagnosed with acute kidney injury (AKI)
in the oliguric phase. Which of the following fluid and electrolyte imbalances
should the nurse expect?
A) Polyuria and hypovolemia.
B) Decreased urine output, hyperkalemia, and fluid overload.
C) Normal electrolyte levels.
D) Hypotension and tachycardia.
E) Improved glomerular filtration rate (GFR).
Correct Answer: B) Decreased urine output, hyperkalemia, and fluid
overload.
Rationale: The oliguric phase of AKI is characterized by a significant
reduction in urine output, leading to fluid retention, accumulation of
electrolytes that are normally excreted (e.g., potassium,
phosphate), and metabolic acidosis.
Question 6
A client with Type 2 Diabetes Mellitus is admitted with hyperglycemic
hyperosmolar state (HHS). The nurse should prioritize which of the following
interventions?
A) Administering a large bolus of regular insulin.
B) Aggressive intravenous fluid resuscitation.
C) Initiating a potassium chloride infusion.
D) Preparing for emergency dialysis.
E) Administering oral glucose.
Correct Answer: B) Aggressive intravenous fluid resuscitation.
Rationale: HHS is characterized by profound dehydration and
, hyperosmolarity without significant ketoacidosis. Aggressive fluid
resuscitation is the primary and most critical initial treatment to
restore circulating volume and gradually lower blood glucose.
Question 7
A nurse is caring for a client with a history of atrial fibrillation who is taking
warfarin. Which of the following lab values should the nurse monitor to
ensure the therapeutic effect of warfarin?
A) Activated Partial Thromboplastin Time (aPTT)
B) Platelet count
C) International Normalized Ratio (INR)
D) Fibrinogen levels
E) D-dimer
Correct Answer: C) International Normalized Ratio (INR)
Rationale: Warfarin's therapeutic effect is monitored by the PT, which
is standardized to the INR (typically 2.0-3.0 for atrial fibrillation),
ensuring consistent anticoagulation.
Question 8
A client is admitted with new onset gastrointestinal bleeding. The nurse
notes the client is hypotensive and tachycardic. Which of the following is the
most appropriate initial nursing action?
A) Administer a proton pump inhibitor (PPI).
B) Obtain a stool sample for occult blood.
C) Insert a nasogastric tube.
D) Establish large-bore IV access and administer prescribed intravenous
fluids.
E) Prepare for endoscopy.
Correct Answer: D) Establish large-bore IV access and administer
prescribed intravenous fluids.
Rationale: Hypotension and tachycardia in a client with GI bleeding
indicate hypovolemic shock. The immediate priority is to establish
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+|
Question 1
A nurse is caring for a client admitted with acute decompensated heart
failure. The client has a new prescription for an intravenous loop diuretic
(e.g., furosemide). Which of the following should the nurse monitor most
closely?
A) Serum sodium and chloride levels.
B) Blood pressure, urine output, and serum potassium.
C) Serum calcium and magnesium levels.
D) Blood glucose levels.
E) Liver function tests.
Correct Answer: B) Blood pressure, urine output, and serum
potassium.
Rationale: Loop diuretics rapidly remove fluid, causing a decrease in
blood pressure and increased urine output. They also lead to
significant potassium excretion, so hypokalemia is a major risk
requiring close monitoring.
Question 2
A client with a history of hypertension and diabetes is admitted with acute
pancreatitis. The nurse should anticipate monitoring for which of the
following complications?
A) Right upper quadrant pain radiating to the right shoulder.
B) Hyperglycemia, hypocalcemia, and acute respiratory distress syndrome
(ARDS).
C) Hypokalemia and metabolic alkalosis.
D) Jaundice with dark urine.
E) Left lower quadrant tenderness.
Correct Answer: B) Hyperglycemia, hypocalcemia, and acute
respiratory distress syndrome (ARDS).
Rationale: Acute pancreatitis can lead to hyperglycemia (pancreatic
,dysfunction), hypocalcemia (fat necrosis consuming calcium), and
can trigger a severe systemic inflammatory response, potentially
leading to ARDS.
Question 3
A nurse is caring for a client admitted with an acute ST-segment elevation
myocardial infarction (STEMI). The client has a new prescription for
metoprolol. The nurse should withhold the medication and notify the provider
if the client exhibits which of the following?
A) Heart rate of 80/min.
B) Blood pressure of 130/80 mmHg.
C) New onset of wheezing.
D) Mild peripheral edema.
E) Chest pain rated 4/10.
Correct Answer: C) New onset of wheezing.
Rationale: Metoprolol is a beta-blocker. New onset wheezing could
indicate bronchospasm, particularly in clients with reactive airway
disease (asthma, COPD), which is a contraindication or requires
caution with beta-blockers.
Question 4
A client is admitted to the intensive care unit following a cerebral aneurysm
rupture and subarachnoid hemorrhage. The nurse should prioritize
monitoring for which of the following neurological complications?
A) Gradual decrease in blood pressure.
B) Stable neurological assessment findings.
C) Re-bleeding, cerebral vasospasm, and increased intracranial pressure
(ICP).
D) Increased urine output.
E) Peripheral edema.
Correct Answer: C) Re-bleeding, cerebral vasospasm, and increased
intracranial pressure (ICP).
,Rationale: Re-bleeding (re-rupture) and cerebral vasospasm
(narrowing of cerebral blood vessels, typically 3-14 days post-SAH)
are critical and potentially devastating complications. Increased ICP
is a constant threat.
Question 5
A nurse is assessing a client who is diagnosed with acute kidney injury (AKI)
in the oliguric phase. Which of the following fluid and electrolyte imbalances
should the nurse expect?
A) Polyuria and hypovolemia.
B) Decreased urine output, hyperkalemia, and fluid overload.
C) Normal electrolyte levels.
D) Hypotension and tachycardia.
E) Improved glomerular filtration rate (GFR).
Correct Answer: B) Decreased urine output, hyperkalemia, and fluid
overload.
Rationale: The oliguric phase of AKI is characterized by a significant
reduction in urine output, leading to fluid retention, accumulation of
electrolytes that are normally excreted (e.g., potassium,
phosphate), and metabolic acidosis.
Question 6
A client with Type 2 Diabetes Mellitus is admitted with hyperglycemic
hyperosmolar state (HHS). The nurse should prioritize which of the following
interventions?
A) Administering a large bolus of regular insulin.
B) Aggressive intravenous fluid resuscitation.
C) Initiating a potassium chloride infusion.
D) Preparing for emergency dialysis.
E) Administering oral glucose.
Correct Answer: B) Aggressive intravenous fluid resuscitation.
Rationale: HHS is characterized by profound dehydration and
, hyperosmolarity without significant ketoacidosis. Aggressive fluid
resuscitation is the primary and most critical initial treatment to
restore circulating volume and gradually lower blood glucose.
Question 7
A nurse is caring for a client with a history of atrial fibrillation who is taking
warfarin. Which of the following lab values should the nurse monitor to
ensure the therapeutic effect of warfarin?
A) Activated Partial Thromboplastin Time (aPTT)
B) Platelet count
C) International Normalized Ratio (INR)
D) Fibrinogen levels
E) D-dimer
Correct Answer: C) International Normalized Ratio (INR)
Rationale: Warfarin's therapeutic effect is monitored by the PT, which
is standardized to the INR (typically 2.0-3.0 for atrial fibrillation),
ensuring consistent anticoagulation.
Question 8
A client is admitted with new onset gastrointestinal bleeding. The nurse
notes the client is hypotensive and tachycardic. Which of the following is the
most appropriate initial nursing action?
A) Administer a proton pump inhibitor (PPI).
B) Obtain a stool sample for occult blood.
C) Insert a nasogastric tube.
D) Establish large-bore IV access and administer prescribed intravenous
fluids.
E) Prepare for endoscopy.
Correct Answer: D) Establish large-bore IV access and administer
prescribed intravenous fluids.
Rationale: Hypotension and tachycardia in a client with GI bleeding
indicate hypovolemic shock. The immediate priority is to establish
