NSG137 Exam 2

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Sample questions from NSG137 Exam 2

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 76-year-old client on a medical-surgical unit has a temperature of 39.1 C (102.4 F), heart rate 126/min, respirations 28/min, blood pressure 84/48 mm Hg, and new confusion. Which action should the nurse take first?

   • A.Activate the rapid response system and initiate the facility sepsis protocol
   • B.Administer the prescribed acetaminophen
   • C.Obtain a urine specimen before taking further action
   • D.Reassess the blood pressure in 30 minutes

   Rationale: Hypotension, tachycardia, fever, tachypnea, and altered mentation indicate possible sepsis with impaired perfusion, so urgent escalation is the priority. Acetaminophen may reduce fever but does not address shock. Collecting a specimen is appropriate when it does not delay stabilization, and waiting to reassess is unsafe.

2. 2.A 68-year-old client with dysphagia after a stroke is eating breakfast in a rehabilitation facility. The client begins coughing, has a wet voice, and oxygen saturation drops from 96% to 89%. What should the nurse do first?

   • A.Stop feeding and position the client upright
   • B.Offer a sip of water to clear the throat
   • C.Ask the client to finish the bite before pausing
   • D.Place the client supine and assess lung sounds

   Rationale: Coughing, wet voice, and desaturation suggest aspiration, so the nurse should stop oral intake and support a safe upright position. Water may worsen aspiration in a client with dysphagia. Continuing the bite or placing the client supine increases airway risk.

3. 3.A 54-year-old client in the emergency department has crushing chest pain, diaphoresis, and an ECG showing ST-segment elevation. Blood pressure is 138/82 mm Hg and oxygen saturation is 96% on room air. Which action is the priority?

   • A.Activate the prescribed reperfusion pathway
   • B.Apply oxygen at 4 L/min by nasal cannula
   • C.Obtain a detailed dietary history
   • D.Encourage the client to walk to reduce anxiety

   Rationale: ST-segment elevation with ischemic symptoms requires rapid reperfusion to limit myocardial injury. Routine oxygen is not indicated solely because the client has chest pain when saturation is adequate. History-taking can follow urgent treatment, and ambulation increases cardiac workload.

4. 4.A 72-year-old client hospitalized with heart failure has increasing dyspnea, crackles, and oxygen saturation of 88% on room air. The client is sitting upright and has a prescription for IV furosemide. Which action should the nurse take first?

   • A.Apply supplemental oxygen and reassess respiratory status
   • B.Administer the furosemide and leave the client to rest
   • C.Encourage oral fluids to thin secretions
   • D.Lower the head of the bed to improve venous return

   Answer and rationale are in the full material.

5. 5.A 63-year-old client with COPD is admitted to a medical unit with increased work of breathing. The client is alert, has an oxygen saturation of 86% on room air, and is prescribed oxygen to maintain a target saturation of 88% to 92%. Which intervention is appropriate?

   • A.Start low-flow oxygen and titrate to the prescribed target
   • B.Withhold oxygen because the client has COPD
   • C.Apply a nonrebreather mask at 15 L/min and leave it unchanged
   • D.Have the client breathe into a paper bag

   Answer and rationale are in the full material.