NURS 4431 EXAM II STUDY GUIDE | 2025/2026
UPDATE | QUESTIONS AND ANSWERS | ALREADY
PASSED.
A nurse is caring for a client who is receiving total parenteral nutrition via a
peripherally inserted central catheter (PICC). When assessing the client, the
nurse notes swelling of the client's arm above the PICC insertion site. Which of
the following actions should the nurse take first?
A. Measure the circumference of both upper arms.
B. Notify the provider who inserted the PICC line.
C. Remove the PICC line.
D. Apply a cold pack to the client's upper arm. Answer - A. Measure the
circumference of both upper arms.
A nurse is caring for a client who has congestive heart failure and is taking
digoxin daily. The client refused breakfast and is complaining of nausea and
weakness. Which of the following actions should the nurse take first?
A. Check the client's vital signs.
B. Request a dietitian consult.
C. Suggest that the client rests before eating the meal.
D. Request an order for an antiemetic. Answer - A. Check the client's vital
signs.
,A nurse in an emergency department is caring for a client who is bleeding
profusely from a deep laceration on his left lower forearm. After observing
standard precautions, which of the following actions should the nurse perform
first?
A. Apply a tourniquet just below the elbow.
B. Apply direct pressure over the wound.
C. Clean the wound.
D. Elevate the limb and apply ice. Answer - B. Apply direct pressure over the
wound.
A nurse is caring for a client who has infective endocarditis. Which of the
following manifestations is the priority for the nurse to monitor for?
A. Anorexia
B. Dyspnea
C. Fever
D. Malaise Answer - B. Dyspnea
A nurse in an emergency department is caring for a client who has a deep
laceration on her left lower forearm and is bleeding heavily from the wound.
Which of the following interventions should the nurse perform first?
A. Apply a tourniquet just above the wound.
B. Apply pressure directly to the wound.
C. Start two large-bore IV catheters.
D. Place the client in a modified Trendelenburg position. Answer - B. Apply
pressure directly to the wound.
,A nurse in the emergency room is caring for a client who presents with
manifestations that indicate a myocardial infarction. Which of the following
prescriptions should the nurse take first?
A. Attach the leads for a 12-lead ECG.
B. Obtain a blood sample.
C. Initiate oxygen therapy.
D. Insert the IV catheter. Answer - C. Initiate oxygen therapy.
A nurse is collecting a medication history from a client who is scheduled to
have a cardiac catheterization. Which of the following medications taken by the
client interacts with contrast material and places the client at risk for acute
kidney injury?
A. Atorvastatin
B. Metformin
C. Nitroglycerin
D. Carvedilol Answer - B. Metformin
A nurse is planning to administer digoxin to a client who has heart failure.
Which of the following laboratory results is the priority for the nurse to review
prior to administering the medication?
A. Potassium
B. Hemoglobin
C. Creatinine
D. Blood urea nitrogen Answer - A. Potassium
, A nurse is caring for a client who has atrial fibrillation and is receiving heparin.
Which of the following findings is the nurse's priority?
A. The client's ECG tracing shows irregular heart rate without P waves.
B. The client has an aPTT of 80 seconds.
C. The client experiences sudden weakness of one arm and leg.
D. The client's urine output is cloudy and odorous. Answer - C. The client
experiences sudden weakness of one arm and leg.
A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the
client's blood pressure is 60/50 mm Hg. Which of the following actions should
the nurse take first?
A. Evaluate the firmness of the uterus.
B. Initiate oxygen therapy by nonrebreather mask.
C. Administer oxytocin infusion.
D. Obtain a type and crossmatch. Answer - A. Evaluate the firmness of the
uterus.
A nurse is reviewing laboratory results of a client who has atrial fibrillation and
is taking warfarin. For which of the following results should the nurse notify the
provider?
A. PT 45 seconds
B. Hgb 16 g/dL
C. Hct 44%
D. Platelets 190,000/mm3 Answer - A. PT 45 seconds
UPDATE | QUESTIONS AND ANSWERS | ALREADY
PASSED.
A nurse is caring for a client who is receiving total parenteral nutrition via a
peripherally inserted central catheter (PICC). When assessing the client, the
nurse notes swelling of the client's arm above the PICC insertion site. Which of
the following actions should the nurse take first?
A. Measure the circumference of both upper arms.
B. Notify the provider who inserted the PICC line.
C. Remove the PICC line.
D. Apply a cold pack to the client's upper arm. Answer - A. Measure the
circumference of both upper arms.
A nurse is caring for a client who has congestive heart failure and is taking
digoxin daily. The client refused breakfast and is complaining of nausea and
weakness. Which of the following actions should the nurse take first?
A. Check the client's vital signs.
B. Request a dietitian consult.
C. Suggest that the client rests before eating the meal.
D. Request an order for an antiemetic. Answer - A. Check the client's vital
signs.
,A nurse in an emergency department is caring for a client who is bleeding
profusely from a deep laceration on his left lower forearm. After observing
standard precautions, which of the following actions should the nurse perform
first?
A. Apply a tourniquet just below the elbow.
B. Apply direct pressure over the wound.
C. Clean the wound.
D. Elevate the limb and apply ice. Answer - B. Apply direct pressure over the
wound.
A nurse is caring for a client who has infective endocarditis. Which of the
following manifestations is the priority for the nurse to monitor for?
A. Anorexia
B. Dyspnea
C. Fever
D. Malaise Answer - B. Dyspnea
A nurse in an emergency department is caring for a client who has a deep
laceration on her left lower forearm and is bleeding heavily from the wound.
Which of the following interventions should the nurse perform first?
A. Apply a tourniquet just above the wound.
B. Apply pressure directly to the wound.
C. Start two large-bore IV catheters.
D. Place the client in a modified Trendelenburg position. Answer - B. Apply
pressure directly to the wound.
,A nurse in the emergency room is caring for a client who presents with
manifestations that indicate a myocardial infarction. Which of the following
prescriptions should the nurse take first?
A. Attach the leads for a 12-lead ECG.
B. Obtain a blood sample.
C. Initiate oxygen therapy.
D. Insert the IV catheter. Answer - C. Initiate oxygen therapy.
A nurse is collecting a medication history from a client who is scheduled to
have a cardiac catheterization. Which of the following medications taken by the
client interacts with contrast material and places the client at risk for acute
kidney injury?
A. Atorvastatin
B. Metformin
C. Nitroglycerin
D. Carvedilol Answer - B. Metformin
A nurse is planning to administer digoxin to a client who has heart failure.
Which of the following laboratory results is the priority for the nurse to review
prior to administering the medication?
A. Potassium
B. Hemoglobin
C. Creatinine
D. Blood urea nitrogen Answer - A. Potassium
, A nurse is caring for a client who has atrial fibrillation and is receiving heparin.
Which of the following findings is the nurse's priority?
A. The client's ECG tracing shows irregular heart rate without P waves.
B. The client has an aPTT of 80 seconds.
C. The client experiences sudden weakness of one arm and leg.
D. The client's urine output is cloudy and odorous. Answer - C. The client
experiences sudden weakness of one arm and leg.
A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the
client's blood pressure is 60/50 mm Hg. Which of the following actions should
the nurse take first?
A. Evaluate the firmness of the uterus.
B. Initiate oxygen therapy by nonrebreather mask.
C. Administer oxytocin infusion.
D. Obtain a type and crossmatch. Answer - A. Evaluate the firmness of the
uterus.
A nurse is reviewing laboratory results of a client who has atrial fibrillation and
is taking warfarin. For which of the following results should the nurse notify the
provider?
A. PT 45 seconds
B. Hgb 16 g/dL
C. Hct 44%
D. Platelets 190,000/mm3 Answer - A. PT 45 seconds
