NUR 265 – EXAM 4 | Questions and Answers
| 2025 Update | 100% Correct - Dorcas
Q1. A patient with pneumonia presents with shortness of breath and O₂ saturation of 88%.
What is the priority nursing action?
A. Administer antibiotics
B. Encourage fluids
C. Administer oxygen
D. Obtain sputum culture
Correct answer: C. Administer oxygen
Rationale: Airway and breathing are the priority (ABC). Oxygen should be given immediately
to correct hypoxia before other interventions.
Q2. Which breath sound is most indicative of pneumonia?
A. Wheezes
B. Crackles
C. Stridor
D. Rhonchi
Correct answer: B. Crackles
Rationale: Crackles are caused by fluid in the alveoli, which is characteristic of pneumonia.
Q3. A COPD patient is receiving oxygen therapy. What is the target oxygen saturation?
A. 100%
B. 95–100%
C. 88–92%
D. 80–85%
Correct answer: C. 88–92%
Rationale: COPD patients rely on hypoxic drive; too much oxygen can suppress breathing.
Q4. A patient reports chest pain. What is the nurse’s first action?
A. Administer nitroglycerin
B. Obtain ECG
,C. Assess vital signs
D. Call the provider
Correct answer: C. Assess vital signs
Rationale: Assessment comes first. Vital signs help determine stability before interventions.
Q5. Which lab value is most specific for heart failure?
A. Troponin
B. BNP
C. WBC
D. Hemoglobin
Correct answer: B. BNP
Rationale: BNP is released when the heart is stretched and is a key marker for heart failure.
Q6. What should the nurse do before administering digoxin?
A. Check blood pressure
B. Check apical pulse
C. Check oxygen level
D. Check temperature
Correct answer: B. Check apical pulse
Rationale: Digoxin slows heart rate; hold if pulse is <60 bpm to prevent bradycardia.
Q7. What is the priority treatment for sepsis?
A. Pain medication
B. Antibiotics and IV fluids
C. Bed rest
D. Oxygen only
Correct answer: B. Antibiotics and IV fluids
Rationale: Early antibiotics and fluid resuscitation are critical to prevent septic shock.
Q8. Which finding indicates septic shock?
A. Fever
B. Elevated WBC
C. Hypotension unresponsive to fluids
D. Tachycardia
,Correct answer: C. Hypotension unresponsive to fluids
Rationale: This is a defining feature of septic shock and requires urgent intervention.
Q9. What is the antidote for opioid overdose?
A. Epinephrine
B. Naloxone
C. Atropine
D. Dopamine
Correct answer: B. Naloxone
Rationale: Naloxone reverses opioid effects, especially respiratory depression.
Q10. What should be monitored when administering vancomycin?
A. Blood glucose
B. Trough levels
C. Blood pressure
D. Heart rate
Correct answer: B. Trough levels
Rationale: Monitoring prevents toxicity and ensures therapeutic levels.
Q11. Which patient should the nurse see first?
A. Patient with fever of 38°C
B. Patient with chest pain
C. Patient with mild headache
D. Patient requesting discharge instructions
Correct answer: B. Patient with chest pain
Rationale: Chest pain may indicate a life-threatening cardiac event.
Q12. What is the first step in managing any emergency?
A. Call the provider
B. Start IV fluids
C. Assess ABCs
D. Administer medication
Correct answer: C. Assess ABCs
Rationale: Airway, breathing, and circulation are always the priority.
, Q13. What is the earliest sign of increased intracranial pressure (ICP)?
A. Vomiting
B. Headache
C. Change in level of consciousness
D. Seizures
Correct answer: C. Change in level of consciousness
Rationale: LOC changes occur first due to decreased cerebral perfusion.
Q14. What is the best position for a patient with increased ICP?
A. Flat
B. Trendelenburg
C. Head elevated 30°
D. Side-lying
Correct answer: C. Head elevated 30°
Rationale: Promotes venous drainage and reduces pressure.
Q15. A patient with pneumonia becomes increasingly confused. What does this indicate?
A. Improvement
B. Fatigue
C. Hypoxia
D. Dehydration
Correct answer: C. Hypoxia
Rationale: Confusion is an early sign of decreased oxygen to the brain.
Q16. A patient’s oxygen level drops suddenly. What is the nurse’s FIRST action?
A. Call the provider
B. Apply oxygen
C. Document
D. Give medication
Correct answer: B. Apply oxygen
Rationale: Immediate correction of hypoxia is critical.
🫁 8. Advanced Respiratory
| 2025 Update | 100% Correct - Dorcas
Q1. A patient with pneumonia presents with shortness of breath and O₂ saturation of 88%.
What is the priority nursing action?
A. Administer antibiotics
B. Encourage fluids
C. Administer oxygen
D. Obtain sputum culture
Correct answer: C. Administer oxygen
Rationale: Airway and breathing are the priority (ABC). Oxygen should be given immediately
to correct hypoxia before other interventions.
Q2. Which breath sound is most indicative of pneumonia?
A. Wheezes
B. Crackles
C. Stridor
D. Rhonchi
Correct answer: B. Crackles
Rationale: Crackles are caused by fluid in the alveoli, which is characteristic of pneumonia.
Q3. A COPD patient is receiving oxygen therapy. What is the target oxygen saturation?
A. 100%
B. 95–100%
C. 88–92%
D. 80–85%
Correct answer: C. 88–92%
Rationale: COPD patients rely on hypoxic drive; too much oxygen can suppress breathing.
Q4. A patient reports chest pain. What is the nurse’s first action?
A. Administer nitroglycerin
B. Obtain ECG
,C. Assess vital signs
D. Call the provider
Correct answer: C. Assess vital signs
Rationale: Assessment comes first. Vital signs help determine stability before interventions.
Q5. Which lab value is most specific for heart failure?
A. Troponin
B. BNP
C. WBC
D. Hemoglobin
Correct answer: B. BNP
Rationale: BNP is released when the heart is stretched and is a key marker for heart failure.
Q6. What should the nurse do before administering digoxin?
A. Check blood pressure
B. Check apical pulse
C. Check oxygen level
D. Check temperature
Correct answer: B. Check apical pulse
Rationale: Digoxin slows heart rate; hold if pulse is <60 bpm to prevent bradycardia.
Q7. What is the priority treatment for sepsis?
A. Pain medication
B. Antibiotics and IV fluids
C. Bed rest
D. Oxygen only
Correct answer: B. Antibiotics and IV fluids
Rationale: Early antibiotics and fluid resuscitation are critical to prevent septic shock.
Q8. Which finding indicates septic shock?
A. Fever
B. Elevated WBC
C. Hypotension unresponsive to fluids
D. Tachycardia
,Correct answer: C. Hypotension unresponsive to fluids
Rationale: This is a defining feature of septic shock and requires urgent intervention.
Q9. What is the antidote for opioid overdose?
A. Epinephrine
B. Naloxone
C. Atropine
D. Dopamine
Correct answer: B. Naloxone
Rationale: Naloxone reverses opioid effects, especially respiratory depression.
Q10. What should be monitored when administering vancomycin?
A. Blood glucose
B. Trough levels
C. Blood pressure
D. Heart rate
Correct answer: B. Trough levels
Rationale: Monitoring prevents toxicity and ensures therapeutic levels.
Q11. Which patient should the nurse see first?
A. Patient with fever of 38°C
B. Patient with chest pain
C. Patient with mild headache
D. Patient requesting discharge instructions
Correct answer: B. Patient with chest pain
Rationale: Chest pain may indicate a life-threatening cardiac event.
Q12. What is the first step in managing any emergency?
A. Call the provider
B. Start IV fluids
C. Assess ABCs
D. Administer medication
Correct answer: C. Assess ABCs
Rationale: Airway, breathing, and circulation are always the priority.
, Q13. What is the earliest sign of increased intracranial pressure (ICP)?
A. Vomiting
B. Headache
C. Change in level of consciousness
D. Seizures
Correct answer: C. Change in level of consciousness
Rationale: LOC changes occur first due to decreased cerebral perfusion.
Q14. What is the best position for a patient with increased ICP?
A. Flat
B. Trendelenburg
C. Head elevated 30°
D. Side-lying
Correct answer: C. Head elevated 30°
Rationale: Promotes venous drainage and reduces pressure.
Q15. A patient with pneumonia becomes increasingly confused. What does this indicate?
A. Improvement
B. Fatigue
C. Hypoxia
D. Dehydration
Correct answer: C. Hypoxia
Rationale: Confusion is an early sign of decreased oxygen to the brain.
Q16. A patient’s oxygen level drops suddenly. What is the nurse’s FIRST action?
A. Call the provider
B. Apply oxygen
C. Document
D. Give medication
Correct answer: B. Apply oxygen
Rationale: Immediate correction of hypoxia is critical.
🫁 8. Advanced Respiratory
