NUR 254 Practice Exam | Questions and
Answers | 2026 Update | 100% Correct –
GT.
1. A newborn has a heart rate of 100 bpm, respirations of 60/min,
and some flexion of extremities. Using the APGAR score, what is
the score at 1 minute?
a) 5
b) 6
c) 7
d) 8
Rationale: The APGAR score assigns 2 points for heart rate >100, 1
point for some flexion, and 1 point for respirations >60/min with
some effort, totaling 7.
2. A client is 32 weeks pregnant and reports bright red vaginal
bleeding. What is the priority nursing action?
a) Obtain a urinalysis
b) Assess maternal vital signs and fetal heart rate
c) Prepare for routine vaginal exam
d) Encourage bed rest
Rationale: Bright red bleeding in the third trimester could indicate
placenta previa or abruption. Immediate assessment of maternal and
fetal status is critical.
3. A patient with diabetes is experiencing a hypoglycemic episode.
Which symptom is least likely to be present?
,a) Tremors
b) Diaphoresis
c) Polyuria
d) Palpitations
Rationale: Polyuria is a symptom of hyperglycemia, not
hypoglycemia. Hypoglycemia typically presents with tremors,
sweating, and palpitations.
4. A 2-year-old child presents with a barking cough and stridor. The
nurse suspects:
a) Bronchiolitis
b) Croup (laryngotracheobronchitis)
c) Asthma
d) Pertussis
Rationale: Croup presents with a characteristic barking cough,
inspiratory stridor, and hoarseness in toddlers.
5. Which lab value indicates adequate anticoagulation for a patient
on heparin therapy?
a) INR 1.0
b) aPTT 60–80 seconds
c) PT 10–12 seconds
d) Platelets 250,000/mm³
Rationale: Heparin therapy is monitored via aPTT. The therapeutic
range is typically 1.5–2.5 times the control value (30–40 sec).
6. A client with preeclampsia develops severe headache and visual
disturbances. The nurse should first:
,a) Administer antihypertensive medication
b) Assess for signs of impending eclampsia
c) Encourage rest in a dark room
d) Increase IV fluids
Rationale: Severe headache and visual changes may indicate
worsening preeclampsia with risk for eclampsia. Immediate
assessment and reporting are crucial.
7. During a blood transfusion, the patient reports chills and back
pain. What is the priority action?
a) Slow the infusion
b) Stop the transfusion and notify the provider
c) Administer acetaminophen
d) Document the reaction
Rationale: These are signs of a hemolytic transfusion reaction.
Stopping the transfusion immediately is essential to prevent further
complications.
8. Which food is most appropriate for a child with iron-deficiency
anemia?
a) Milk
b) White rice
c) Lean red meat
d) Potato chips
Rationale: Iron-rich foods such as lean red meat help replenish iron
stores. Milk can inhibit iron absorption.
9. A patient with chronic obstructive pulmonary disease (COPD) has
oxygen saturation of 86%. The nurse should:
, a) Increase oxygen to 6 L/min
b) Encourage deep breathing and coughing
c) Administer oxygen at 1–2 L/min via nasal cannula and monitor
response
d) Place the patient in Trendelenburg position
Rationale: COPD patients are at risk for CO2 retention. Oxygen should
be titrated carefully, typically 1–2 L/min, with close monitoring.
10. A 3-day-old newborn has jaundice with total bilirubin of 16
mg/dL. The nurse should:
a) Assess feeding pattern
b) Notify the healthcare provider immediately
c) Provide routine newborn care
d) Encourage swaddling
Rationale: Bilirubin >15 mg/dL in term newborns may require
phototherapy to prevent kernicterus.
11. A 6-year-old with asthma is experiencing an acute attack. The
first-line treatment is:
a) Oral corticosteroids
b) Short-acting beta-agonist inhaler
c) IV antibiotics
d) Oxygen only
Rationale: Quick-relief therapy with a short-acting beta-agonist (e.g.,
albuterol) is the first-line treatment during acute asthma
exacerbations.
12. Which intervention is priority for a postoperative patient at risk
for deep vein thrombosis (DVT)?
Answers | 2026 Update | 100% Correct –
GT.
1. A newborn has a heart rate of 100 bpm, respirations of 60/min,
and some flexion of extremities. Using the APGAR score, what is
the score at 1 minute?
a) 5
b) 6
c) 7
d) 8
Rationale: The APGAR score assigns 2 points for heart rate >100, 1
point for some flexion, and 1 point for respirations >60/min with
some effort, totaling 7.
2. A client is 32 weeks pregnant and reports bright red vaginal
bleeding. What is the priority nursing action?
a) Obtain a urinalysis
b) Assess maternal vital signs and fetal heart rate
c) Prepare for routine vaginal exam
d) Encourage bed rest
Rationale: Bright red bleeding in the third trimester could indicate
placenta previa or abruption. Immediate assessment of maternal and
fetal status is critical.
3. A patient with diabetes is experiencing a hypoglycemic episode.
Which symptom is least likely to be present?
,a) Tremors
b) Diaphoresis
c) Polyuria
d) Palpitations
Rationale: Polyuria is a symptom of hyperglycemia, not
hypoglycemia. Hypoglycemia typically presents with tremors,
sweating, and palpitations.
4. A 2-year-old child presents with a barking cough and stridor. The
nurse suspects:
a) Bronchiolitis
b) Croup (laryngotracheobronchitis)
c) Asthma
d) Pertussis
Rationale: Croup presents with a characteristic barking cough,
inspiratory stridor, and hoarseness in toddlers.
5. Which lab value indicates adequate anticoagulation for a patient
on heparin therapy?
a) INR 1.0
b) aPTT 60–80 seconds
c) PT 10–12 seconds
d) Platelets 250,000/mm³
Rationale: Heparin therapy is monitored via aPTT. The therapeutic
range is typically 1.5–2.5 times the control value (30–40 sec).
6. A client with preeclampsia develops severe headache and visual
disturbances. The nurse should first:
,a) Administer antihypertensive medication
b) Assess for signs of impending eclampsia
c) Encourage rest in a dark room
d) Increase IV fluids
Rationale: Severe headache and visual changes may indicate
worsening preeclampsia with risk for eclampsia. Immediate
assessment and reporting are crucial.
7. During a blood transfusion, the patient reports chills and back
pain. What is the priority action?
a) Slow the infusion
b) Stop the transfusion and notify the provider
c) Administer acetaminophen
d) Document the reaction
Rationale: These are signs of a hemolytic transfusion reaction.
Stopping the transfusion immediately is essential to prevent further
complications.
8. Which food is most appropriate for a child with iron-deficiency
anemia?
a) Milk
b) White rice
c) Lean red meat
d) Potato chips
Rationale: Iron-rich foods such as lean red meat help replenish iron
stores. Milk can inhibit iron absorption.
9. A patient with chronic obstructive pulmonary disease (COPD) has
oxygen saturation of 86%. The nurse should:
, a) Increase oxygen to 6 L/min
b) Encourage deep breathing and coughing
c) Administer oxygen at 1–2 L/min via nasal cannula and monitor
response
d) Place the patient in Trendelenburg position
Rationale: COPD patients are at risk for CO2 retention. Oxygen should
be titrated carefully, typically 1–2 L/min, with close monitoring.
10. A 3-day-old newborn has jaundice with total bilirubin of 16
mg/dL. The nurse should:
a) Assess feeding pattern
b) Notify the healthcare provider immediately
c) Provide routine newborn care
d) Encourage swaddling
Rationale: Bilirubin >15 mg/dL in term newborns may require
phototherapy to prevent kernicterus.
11. A 6-year-old with asthma is experiencing an acute attack. The
first-line treatment is:
a) Oral corticosteroids
b) Short-acting beta-agonist inhaler
c) IV antibiotics
d) Oxygen only
Rationale: Quick-relief therapy with a short-acting beta-agonist (e.g.,
albuterol) is the first-line treatment during acute asthma
exacerbations.
12. Which intervention is priority for a postoperative patient at risk
for deep vein thrombosis (DVT)?
