NURS 5433 MIDTERM EXAM ACTUAL QUESTIONS
AND ANSWERS - LATEST AND COMPLETE UPDATE
WITH VERIFIED SOLUTIONS – ASSURED PASS WITH
INSTANT DOWNLOAD PDF.
1. A patient with chronic obstructive pulmonary disease (COPD) reports
increased shortness of breath and a productive cough with green sputum.
Which nursing action is most appropriate first?
A. Administer a bronchodilator as prescribed
B. Assess oxygen saturation and respiratory rate
C. Teach pursed-lip breathing
D. Encourage fluid intake
Rationale: Assessing oxygen saturation and respiratory rate provides immediate
information about the patient’s respiratory status, which guides urgent
interventions before other measures.
2. A nurse is caring for a patient receiving intravenous morphine for
postoperative pain. The patient becomes drowsy and has a respiratory rate of
8 breaths per minute. What is the priority nursing action?
A. Monitor vital signs every 15 minutes
B. Call the healthcare provider after documentation
C. Administer naloxone as prescribed
D. Encourage the patient to take deep breaths
Rationale: Naloxone is an opioid antagonist used to reverse respiratory depression
caused by morphine. Immediate action is necessary to prevent hypoxia.
, 3. A nurse is teaching a patient about self-management of type 2 diabetes.
Which statement by the patient indicates a need for further teaching?
A. “I should check my blood sugar before meals.”
B. “I will try to maintain a healthy weight.”
C. “I can skip insulin if I feel fine.”
D. “I should monitor for signs of hyperglycemia.”
Rationale: Skipping insulin is unsafe and can lead to hyperglycemia and diabetic
ketoacidosis. The patient requires further education.
4. A patient on warfarin therapy presents with bruising and bleeding gums.
Which lab value is most important for the nurse to check?
A. Hemoglobin
B. International Normalized Ratio (INR)
C. Platelet count
D. Prothrombin time (PT)
Rationale: INR specifically evaluates the therapeutic effect of warfarin and the risk
of bleeding, making it the priority lab to assess.
5. A 45-year-old patient has a blood pressure of 180/110 mmHg. Which
statement best reflects the nurse’s understanding of hypertension
management?
A. Initiate lifestyle changes only
B. Immediate pharmacologic intervention is indicated
C. Monitor BP daily without intervention
D. Advise the patient to reduce stress only
,Rationale: A BP of 180/110 mmHg indicates hypertensive urgency/emergency;
immediate pharmacologic intervention is required to prevent organ damage.
6. A nurse observes a colleague documenting care that was not provided. What
is the most appropriate initial action?
A. Ignore the behavior
B. Report the incident to the charge nurse or supervisor
C. Confront the colleague aggressively
D. Document the observation in the patient chart
Rationale: Patient safety and professional integrity require reporting unsafe or
unethical behavior to a supervisor rather than ignoring it or confronting
inappropriately.
7. A patient with heart failure has gained 3 pounds in 2 days and reports
swelling in the ankles. Which intervention should the nurse implement first?
A. Encourage exercise
B. Assess lung sounds and oxygenation
C. Restrict fluid intake
D. Notify dietitian
Rationale: Sudden weight gain and edema may indicate fluid overload. Assessing
respiratory status ensures early detection of pulmonary edema.
8. A nurse is administering a new medication to a patient. Which action reflects
safe medication administration?
A. Administer without verifying the patient’s allergies
B. Check the medication against the MAR three times before
administration
, C. Rely solely on memory for dosage calculations
D. Document administration before giving the medication
Rationale: The “three checks” process prevents medication errors and ensures
patient safety.
9. A patient with acute kidney injury has a potassium level of 6.2 mEq/L.
Which is the most urgent nursing intervention?
A. Start a low-potassium diet
B. Administer prescribed kayexalate or insulin with glucose
C. Encourage oral fluids
D. Monitor potassium daily
Rationale: Hyperkalemia can cause life-threatening arrhythmias. Immediate
intervention to lower potassium is critical.
10.A patient with severe anxiety refuses medication. Which nursing response
demonstrates therapeutic communication?
A. “You must take this medication or your condition will worsen.”
B. “I understand you’re feeling anxious. Can we talk about what
concerns you about the medication?”
C. “You will feel better if you just take it.”
D. “You’re being irrational; this is for your own good.”
Rationale: Therapeutic communication involves validating feelings and exploring
patient concerns without judgment.
11.A patient is receiving enteral feeding through a nasogastric tube. Which
action is most important to prevent aspiration?
AND ANSWERS - LATEST AND COMPLETE UPDATE
WITH VERIFIED SOLUTIONS – ASSURED PASS WITH
INSTANT DOWNLOAD PDF.
1. A patient with chronic obstructive pulmonary disease (COPD) reports
increased shortness of breath and a productive cough with green sputum.
Which nursing action is most appropriate first?
A. Administer a bronchodilator as prescribed
B. Assess oxygen saturation and respiratory rate
C. Teach pursed-lip breathing
D. Encourage fluid intake
Rationale: Assessing oxygen saturation and respiratory rate provides immediate
information about the patient’s respiratory status, which guides urgent
interventions before other measures.
2. A nurse is caring for a patient receiving intravenous morphine for
postoperative pain. The patient becomes drowsy and has a respiratory rate of
8 breaths per minute. What is the priority nursing action?
A. Monitor vital signs every 15 minutes
B. Call the healthcare provider after documentation
C. Administer naloxone as prescribed
D. Encourage the patient to take deep breaths
Rationale: Naloxone is an opioid antagonist used to reverse respiratory depression
caused by morphine. Immediate action is necessary to prevent hypoxia.
, 3. A nurse is teaching a patient about self-management of type 2 diabetes.
Which statement by the patient indicates a need for further teaching?
A. “I should check my blood sugar before meals.”
B. “I will try to maintain a healthy weight.”
C. “I can skip insulin if I feel fine.”
D. “I should monitor for signs of hyperglycemia.”
Rationale: Skipping insulin is unsafe and can lead to hyperglycemia and diabetic
ketoacidosis. The patient requires further education.
4. A patient on warfarin therapy presents with bruising and bleeding gums.
Which lab value is most important for the nurse to check?
A. Hemoglobin
B. International Normalized Ratio (INR)
C. Platelet count
D. Prothrombin time (PT)
Rationale: INR specifically evaluates the therapeutic effect of warfarin and the risk
of bleeding, making it the priority lab to assess.
5. A 45-year-old patient has a blood pressure of 180/110 mmHg. Which
statement best reflects the nurse’s understanding of hypertension
management?
A. Initiate lifestyle changes only
B. Immediate pharmacologic intervention is indicated
C. Monitor BP daily without intervention
D. Advise the patient to reduce stress only
,Rationale: A BP of 180/110 mmHg indicates hypertensive urgency/emergency;
immediate pharmacologic intervention is required to prevent organ damage.
6. A nurse observes a colleague documenting care that was not provided. What
is the most appropriate initial action?
A. Ignore the behavior
B. Report the incident to the charge nurse or supervisor
C. Confront the colleague aggressively
D. Document the observation in the patient chart
Rationale: Patient safety and professional integrity require reporting unsafe or
unethical behavior to a supervisor rather than ignoring it or confronting
inappropriately.
7. A patient with heart failure has gained 3 pounds in 2 days and reports
swelling in the ankles. Which intervention should the nurse implement first?
A. Encourage exercise
B. Assess lung sounds and oxygenation
C. Restrict fluid intake
D. Notify dietitian
Rationale: Sudden weight gain and edema may indicate fluid overload. Assessing
respiratory status ensures early detection of pulmonary edema.
8. A nurse is administering a new medication to a patient. Which action reflects
safe medication administration?
A. Administer without verifying the patient’s allergies
B. Check the medication against the MAR three times before
administration
, C. Rely solely on memory for dosage calculations
D. Document administration before giving the medication
Rationale: The “three checks” process prevents medication errors and ensures
patient safety.
9. A patient with acute kidney injury has a potassium level of 6.2 mEq/L.
Which is the most urgent nursing intervention?
A. Start a low-potassium diet
B. Administer prescribed kayexalate or insulin with glucose
C. Encourage oral fluids
D. Monitor potassium daily
Rationale: Hyperkalemia can cause life-threatening arrhythmias. Immediate
intervention to lower potassium is critical.
10.A patient with severe anxiety refuses medication. Which nursing response
demonstrates therapeutic communication?
A. “You must take this medication or your condition will worsen.”
B. “I understand you’re feeling anxious. Can we talk about what
concerns you about the medication?”
C. “You will feel better if you just take it.”
D. “You’re being irrational; this is for your own good.”
Rationale: Therapeutic communication involves validating feelings and exploring
patient concerns without judgment.
11.A patient is receiving enteral feeding through a nasogastric tube. Which
action is most important to prevent aspiration?
