NURS 4431 EXAM II STUDY GUIDE NEwEST UpDATE 2025 wITh
CoMplETE QUESTIoNS AND CoRRECT DETAIlED ANSwERS (VERIfIED
ANSwERS) |AlREADY GRADED A+|BRAND NEw VERSIoN!!
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. - CoRRECT 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. - CoRRECT ANSwER-B. Apply direct pressure over the wound.
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. - CoRRECT ANSwER-A. Measure the
circumference of both upper arms.
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 - CoRRECT 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. - CoRRECT 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. - CoRRECT 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 - CoRRECT 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 - CoRRECT 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. - CoRRECT 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. - CoRRECT 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 - CoRRECT ANSwER-A. PT 45 seconds
A nurse is assessing a client who has fluid overload. Which of the following findings should the
nurse expect? (Select all that apply.)
A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
D. Increase hematocrit
E. Increased temperature - CoRRECT ANSwER-A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac
dysrhythmias. For which of the following adverse effects should the nurse monitor when giving
this medication?
A. Hyperthermia
CoMplETE QUESTIoNS AND CoRRECT DETAIlED ANSwERS (VERIfIED
ANSwERS) |AlREADY GRADED A+|BRAND NEw VERSIoN!!
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. - CoRRECT 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. - CoRRECT ANSwER-B. Apply direct pressure over the wound.
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. - CoRRECT ANSwER-A. Measure the
circumference of both upper arms.
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 - CoRRECT 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. - CoRRECT 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. - CoRRECT 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 - CoRRECT 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 - CoRRECT 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. - CoRRECT 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. - CoRRECT 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 - CoRRECT ANSwER-A. PT 45 seconds
A nurse is assessing a client who has fluid overload. Which of the following findings should the
nurse expect? (Select all that apply.)
A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
D. Increase hematocrit
E. Increased temperature - CoRRECT ANSwER-A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac
dysrhythmias. For which of the following adverse effects should the nurse monitor when giving
this medication?
A. Hyperthermia
