NUR 254 EXAM 1–4 ACTUAL QUESTIONS AND
ANSWERS - LATEST AND COMPLETE UPDATE
WITH VERIFIED SOLUTIONS – ASSURED PASS
WITH INSTANT DOWNLOAD PDF.
1. A nurse is assessing a postoperative adult client who received large volumes
of IV fluids. Which finding most strongly suggests fluid volume overload?
A. Dry mucous membranes
B. Decreased urine output
C. Crackles auscultated in the lung bases
D. Poor skin turgor
Rationale: Crackles indicate fluid accumulation in the alveoli and are a
classic sign of fluid volume overload, especially after aggressive IV fluid
administration.
2. A client with prolonged vomiting is at greatest risk for which acid–base
imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Rationale: Loss of gastric acid through vomiting leads to an increase in
blood pH, resulting in metabolic alkalosis.
3. Which nursing action is the priority when administering oxygen via nasal
cannula at 6 L/min?
A. Apply a nonrebreather mask
B. Assess for nasal mucosal dryness
C. Place the client in Trendelenburg position
, D. Limit oxygen therapy to 1 hour
Rationale: Higher oxygen flow rates via nasal cannula can dry and irritate
nasal mucosa, requiring humidification and frequent assessment.
4. A client with heart failure reports sudden weight gain of 2 kg in 2 days.
What is the nurse’s best initial response?
A. Reassure the client this is expected
B. Encourage increased oral fluids
C. Notify the provider of possible fluid retention
D. Document the finding as normal
Rationale: Rapid weight gain indicates fluid retention and possible
worsening heart failure, requiring prompt provider notification.
5. Which electrolyte imbalance places a client at highest risk for cardiac
dysrhythmias?
A. Hyponatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypermagnesemia
Rationale: Potassium directly affects cardiac conduction; elevated levels
can cause life-threatening dysrhythmias.
6. A nurse is caring for a client receiving digoxin. Which laboratory value is
most critical to monitor?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Rationale: Hypokalemia increases the risk of digoxin toxicity, making
potassium monitoring essential.
,7. A client with chronic obstructive pulmonary disease (COPD) has an SpO₂ of
88%. Which action is most appropriate?
A. Apply oxygen at 15 L/min via nonrebreather
B. Administer low-flow oxygen as prescribed
C. Encourage rapid deep breathing
D. Withhold oxygen therapy
Rationale: COPD clients rely on hypoxic drive; low-flow oxygen maintains
adequate saturation without suppressing respiratory drive.
8. When performing tracheostomy care, which action prevents infection?
A. Using sterile gloves only for inner cannula removal
B. Cleaning the stoma with hydrogen peroxide daily
C. Using sterile technique for suctioning
D. Changing tracheostomy ties once weekly
Rationale: Sterile suctioning minimizes the introduction of pathogens into
the airway.
9. A client with anemia reports fatigue and shortness of breath on exertion. The
nurse understands these symptoms occur primarily because of:
A. Increased blood viscosity
B. Reduced plasma volume
C. Decreased oxygen-carrying capacity
D. Impaired platelet function
Rationale: Anemia reduces hemoglobin levels, limiting oxygen delivery to
tissues.
10.Which finding requires immediate intervention in a client receiving a blood
transfusion?
A. Mild flushing
B. Low-grade fever
, C. Sudden dyspnea and chest pain
D. Chills after 30 minutes
Rationale: Sudden dyspnea and chest pain suggest a severe transfusion
reaction and require stopping the transfusion immediately.
11.A nurse is teaching a client about hypertension management. Which
statement indicates correct understanding?
A. “I should stop my medication once my blood pressure is normal.”
B. “Reducing sodium intake can help control my blood pressure.”
C. “Exercise is not recommended for hypertension.”
D. “Only stress causes high blood pressure.”
Rationale: Sodium reduction is a key nonpharmacologic intervention in
hypertension management.
12.A client with chest pain receives nitroglycerin. Which assessment is the
nurse’s priority?
A. Bowel sounds
B. Urine output
C. Blood pressure
D. Temperature
Rationale: Nitroglycerin causes vasodilation and can lead to hypotension,
requiring close blood pressure monitoring.
13.Which finding is most consistent with left-sided heart failure?
A. Peripheral edema
B. Pulmonary crackles
C. Jugular vein distention
D. Ascites
Rationale: Left-sided failure leads to pulmonary congestion, manifested as
crackles.
ANSWERS - LATEST AND COMPLETE UPDATE
WITH VERIFIED SOLUTIONS – ASSURED PASS
WITH INSTANT DOWNLOAD PDF.
1. A nurse is assessing a postoperative adult client who received large volumes
of IV fluids. Which finding most strongly suggests fluid volume overload?
A. Dry mucous membranes
B. Decreased urine output
C. Crackles auscultated in the lung bases
D. Poor skin turgor
Rationale: Crackles indicate fluid accumulation in the alveoli and are a
classic sign of fluid volume overload, especially after aggressive IV fluid
administration.
2. A client with prolonged vomiting is at greatest risk for which acid–base
imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Rationale: Loss of gastric acid through vomiting leads to an increase in
blood pH, resulting in metabolic alkalosis.
3. Which nursing action is the priority when administering oxygen via nasal
cannula at 6 L/min?
A. Apply a nonrebreather mask
B. Assess for nasal mucosal dryness
C. Place the client in Trendelenburg position
, D. Limit oxygen therapy to 1 hour
Rationale: Higher oxygen flow rates via nasal cannula can dry and irritate
nasal mucosa, requiring humidification and frequent assessment.
4. A client with heart failure reports sudden weight gain of 2 kg in 2 days.
What is the nurse’s best initial response?
A. Reassure the client this is expected
B. Encourage increased oral fluids
C. Notify the provider of possible fluid retention
D. Document the finding as normal
Rationale: Rapid weight gain indicates fluid retention and possible
worsening heart failure, requiring prompt provider notification.
5. Which electrolyte imbalance places a client at highest risk for cardiac
dysrhythmias?
A. Hyponatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypermagnesemia
Rationale: Potassium directly affects cardiac conduction; elevated levels
can cause life-threatening dysrhythmias.
6. A nurse is caring for a client receiving digoxin. Which laboratory value is
most critical to monitor?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Rationale: Hypokalemia increases the risk of digoxin toxicity, making
potassium monitoring essential.
,7. A client with chronic obstructive pulmonary disease (COPD) has an SpO₂ of
88%. Which action is most appropriate?
A. Apply oxygen at 15 L/min via nonrebreather
B. Administer low-flow oxygen as prescribed
C. Encourage rapid deep breathing
D. Withhold oxygen therapy
Rationale: COPD clients rely on hypoxic drive; low-flow oxygen maintains
adequate saturation without suppressing respiratory drive.
8. When performing tracheostomy care, which action prevents infection?
A. Using sterile gloves only for inner cannula removal
B. Cleaning the stoma with hydrogen peroxide daily
C. Using sterile technique for suctioning
D. Changing tracheostomy ties once weekly
Rationale: Sterile suctioning minimizes the introduction of pathogens into
the airway.
9. A client with anemia reports fatigue and shortness of breath on exertion. The
nurse understands these symptoms occur primarily because of:
A. Increased blood viscosity
B. Reduced plasma volume
C. Decreased oxygen-carrying capacity
D. Impaired platelet function
Rationale: Anemia reduces hemoglobin levels, limiting oxygen delivery to
tissues.
10.Which finding requires immediate intervention in a client receiving a blood
transfusion?
A. Mild flushing
B. Low-grade fever
, C. Sudden dyspnea and chest pain
D. Chills after 30 minutes
Rationale: Sudden dyspnea and chest pain suggest a severe transfusion
reaction and require stopping the transfusion immediately.
11.A nurse is teaching a client about hypertension management. Which
statement indicates correct understanding?
A. “I should stop my medication once my blood pressure is normal.”
B. “Reducing sodium intake can help control my blood pressure.”
C. “Exercise is not recommended for hypertension.”
D. “Only stress causes high blood pressure.”
Rationale: Sodium reduction is a key nonpharmacologic intervention in
hypertension management.
12.A client with chest pain receives nitroglycerin. Which assessment is the
nurse’s priority?
A. Bowel sounds
B. Urine output
C. Blood pressure
D. Temperature
Rationale: Nitroglycerin causes vasodilation and can lead to hypotension,
requiring close blood pressure monitoring.
13.Which finding is most consistent with left-sided heart failure?
A. Peripheral edema
B. Pulmonary crackles
C. Jugular vein distention
D. Ascites
Rationale: Left-sided failure leads to pulmonary congestion, manifested as
crackles.
