NR 341 NR 341 Exam 2 Questions
And Answers( Complete Solution
Rated A)
Course
NR 341
Question 1
A nurse is caring for a client diagnosed with heart failure. Which assessment finding indicates
fluid volume excess?
A. Dry mucous membranes
B. Weight loss of 2 lb in 24 hours
C. Bilateral crackles in the lungs
D. Decreased jugular venous distention
Answer: C. Bilateral crackles in the lungs
Rationale
Heart failure often causes fluid accumulation in the lungs. Crackles indicate pulmonary
congestion from excess fluid. Dry mucous membranes and weight loss suggest fluid deficit,
while decreased jugular venous distention is not associated with fluid overload.
Question 2
A nurse is teaching a client with hypertension about lifestyle modifications. Which statement by
the client indicates understanding?
A. "I will increase my sodium intake."
B. "I will exercise regularly and maintain a healthy weight."
C. "I will stop taking my medications once my blood pressure improves."
D. "I should avoid eating fruits and vegetables."
Answer: B. "I will exercise regularly and maintain a healthy weight."
Rationale
Regular exercise and weight management help reduce blood pressure. Sodium intake should be
limited, medications should not be discontinued without provider guidance, and fruits and
vegetables are encouraged as part of the DASH diet.
,Question 3
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which
assessment finding requires immediate intervention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 89% on prescribed oxygen
C. Increased drowsiness and confusion
D. Mild productive cough
Answer: C. Increased drowsiness and confusion
Rationale
Increasing drowsiness and confusion may indicate carbon dioxide retention and respiratory
failure. This finding requires immediate assessment and intervention.
Question 4
A nurse is assessing a client for signs of deep vein thrombosis (DVT). Which manifestation is
most concerning?
A. Bilateral leg edema
B. Cool lower extremities
C. Unilateral calf pain and swelling
D. Symmetrical pedal pulses
Answer: C. Unilateral calf pain and swelling
Rationale
Classic signs of DVT include unilateral pain, swelling, warmth, and redness of the affected
extremity.
Question 5
A nurse is caring for a postoperative client. Which action best reduces the risk of atelectasis?
A. Restrict fluid intake
B. Encourage incentive spirometer use
C. Maintain bed rest
D. Administer sedatives frequently
Answer: B. Encourage incentive spirometer use
,Rationale
The incentive spirometer promotes lung expansion and helps prevent postoperative atelectasis.
Question 6
A client with diabetes mellitus reports shakiness, sweating, and hunger. What is the nurse's
priority action?
A. Administer insulin
B. Check the client's blood glucose level
C. Restrict carbohydrates
D. Encourage exercise
Answer: B. Check the client's blood glucose level
Rationale
These symptoms suggest hypoglycemia. The nurse should first assess blood glucose to confirm
the condition before implementing treatment.
Question 7
A nurse is teaching a client prescribed warfarin. Which statement indicates a need for further
teaching?
A. "I will have my INR checked regularly."
B. "I should report unusual bleeding."
C. "I can double my dose if I miss one."
D. "I should use a soft toothbrush."
Answer: C. "I can double my dose if I miss one."
Rationale
Clients should never double doses of warfarin. Doing so increases the risk of serious bleeding
complications.
Question 8
A nurse is caring for a client with pneumonia. Which assessment finding suggests improvement?
A. Increased crackles
B. Temperature of 103°F (39.4°C)
, C. Oxygen saturation increased from 88% to 95%
D. Increased respiratory distress
Answer: C. Oxygen saturation increased from 88% to 95%
Rationale
Improved oxygen saturation indicates better gas exchange and clinical improvement.
Question 9
A nurse is caring for a client experiencing an acute myocardial infarction. Which laboratory
value is most specific for myocardial injury?
A. Hemoglobin
B. Troponin I
C. White blood cell count
D. Potassium
Answer: B. Troponin I
Rationale
Troponin I is highly sensitive and specific for cardiac muscle injury and is a key diagnostic
marker for myocardial infarction.
Question 10
A nurse is preparing to discharge a client with heart failure. Which statement indicates the client
understands discharge instructions?
A. "I will weigh myself daily and report sudden weight gain."
B. "I should stop my medications when I feel better."
C. "I can eat as much salt as I want."
D. "I only need follow-up care if symptoms return."
Answer: A. "I will weigh myself daily and report sudden weight gain."
Rationale
Daily weight monitoring helps identify fluid retention early. Clients with heart failure should
continue prescribed medications, follow dietary restrictions, and attend regular follow-up
appointments.
Question 11
And Answers( Complete Solution
Rated A)
Course
NR 341
Question 1
A nurse is caring for a client diagnosed with heart failure. Which assessment finding indicates
fluid volume excess?
A. Dry mucous membranes
B. Weight loss of 2 lb in 24 hours
C. Bilateral crackles in the lungs
D. Decreased jugular venous distention
Answer: C. Bilateral crackles in the lungs
Rationale
Heart failure often causes fluid accumulation in the lungs. Crackles indicate pulmonary
congestion from excess fluid. Dry mucous membranes and weight loss suggest fluid deficit,
while decreased jugular venous distention is not associated with fluid overload.
Question 2
A nurse is teaching a client with hypertension about lifestyle modifications. Which statement by
the client indicates understanding?
A. "I will increase my sodium intake."
B. "I will exercise regularly and maintain a healthy weight."
C. "I will stop taking my medications once my blood pressure improves."
D. "I should avoid eating fruits and vegetables."
Answer: B. "I will exercise regularly and maintain a healthy weight."
Rationale
Regular exercise and weight management help reduce blood pressure. Sodium intake should be
limited, medications should not be discontinued without provider guidance, and fruits and
vegetables are encouraged as part of the DASH diet.
,Question 3
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which
assessment finding requires immediate intervention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 89% on prescribed oxygen
C. Increased drowsiness and confusion
D. Mild productive cough
Answer: C. Increased drowsiness and confusion
Rationale
Increasing drowsiness and confusion may indicate carbon dioxide retention and respiratory
failure. This finding requires immediate assessment and intervention.
Question 4
A nurse is assessing a client for signs of deep vein thrombosis (DVT). Which manifestation is
most concerning?
A. Bilateral leg edema
B. Cool lower extremities
C. Unilateral calf pain and swelling
D. Symmetrical pedal pulses
Answer: C. Unilateral calf pain and swelling
Rationale
Classic signs of DVT include unilateral pain, swelling, warmth, and redness of the affected
extremity.
Question 5
A nurse is caring for a postoperative client. Which action best reduces the risk of atelectasis?
A. Restrict fluid intake
B. Encourage incentive spirometer use
C. Maintain bed rest
D. Administer sedatives frequently
Answer: B. Encourage incentive spirometer use
,Rationale
The incentive spirometer promotes lung expansion and helps prevent postoperative atelectasis.
Question 6
A client with diabetes mellitus reports shakiness, sweating, and hunger. What is the nurse's
priority action?
A. Administer insulin
B. Check the client's blood glucose level
C. Restrict carbohydrates
D. Encourage exercise
Answer: B. Check the client's blood glucose level
Rationale
These symptoms suggest hypoglycemia. The nurse should first assess blood glucose to confirm
the condition before implementing treatment.
Question 7
A nurse is teaching a client prescribed warfarin. Which statement indicates a need for further
teaching?
A. "I will have my INR checked regularly."
B. "I should report unusual bleeding."
C. "I can double my dose if I miss one."
D. "I should use a soft toothbrush."
Answer: C. "I can double my dose if I miss one."
Rationale
Clients should never double doses of warfarin. Doing so increases the risk of serious bleeding
complications.
Question 8
A nurse is caring for a client with pneumonia. Which assessment finding suggests improvement?
A. Increased crackles
B. Temperature of 103°F (39.4°C)
, C. Oxygen saturation increased from 88% to 95%
D. Increased respiratory distress
Answer: C. Oxygen saturation increased from 88% to 95%
Rationale
Improved oxygen saturation indicates better gas exchange and clinical improvement.
Question 9
A nurse is caring for a client experiencing an acute myocardial infarction. Which laboratory
value is most specific for myocardial injury?
A. Hemoglobin
B. Troponin I
C. White blood cell count
D. Potassium
Answer: B. Troponin I
Rationale
Troponin I is highly sensitive and specific for cardiac muscle injury and is a key diagnostic
marker for myocardial infarction.
Question 10
A nurse is preparing to discharge a client with heart failure. Which statement indicates the client
understands discharge instructions?
A. "I will weigh myself daily and report sudden weight gain."
B. "I should stop my medications when I feel better."
C. "I can eat as much salt as I want."
D. "I only need follow-up care if symptoms return."
Answer: A. "I will weigh myself daily and report sudden weight gain."
Rationale
Daily weight monitoring helps identify fluid retention early. Clients with heart failure should
continue prescribed medications, follow dietary restrictions, and attend regular follow-up
appointments.
Question 11
