NSG 2600/2610 – Adult Health Nursing
Clinical Practicum Questions and Correct
Answers (Verified Answers) Plus
Rationales 2025 Q&A | Instant Download
PDF – Clinical Judgment, Prioritization,
Skills, Pathophysiology & Safety
Clinical Judgment & Prioritization
1. A nurse is caring for a client post-abdominal surgery. Which assessment
finding requires immediate action?
• A) Hypoactive bowel sounds
• B) Pain level of 5/10
• C) Firm, distended abdomen
• D) Serosanguinous drainage on dressing
Answer: C
Rationale: A firm, distended abdomen may indicate internal bleeding or paralytic
ileus, requiring immediate intervention .
2. A patient is receiving IV morphine. Which nursing action has the highest
priority?
• A) Monitor for nausea
, • B) Assess for itching
• C) Check respiratory rate
• D) Evaluate pain relief
Answer: C
Rationale: Opioids like morphine can cause respiratory depression, making
respiratory assessment a priority .
3. A nurse notes that a patient’s surgical wound has eviscerated. What is the
priority nursing intervention?
• A) Call the provider
• B) Apply a dry sterile dressing
• C) Cover the wound with sterile saline-soaked gauze
• D) Reinsert the organs gently
Answer: C
Rationale: Evisceration is a medical emergency; moist gauze helps prevent tissue
drying and infection until surgery .
4. A client with COPD is on 2L nasal cannula. Which assessment would
prompt immediate action?
• A) O2 saturation of 91%
• B) Barrel chest
• C) Respiratory rate of 8/min
• D) Clubbed fingers
Answer: C
*Rationale: A RR of 8/min indicates respiratory depression, which is life-
threatening in a COPD patient .*
5. Which action should the nurse prioritize after a new central line is placed?
, • A) Begin IV fluids
• B) Obtain chest x-ray
• C) Document the procedure
• D) Apply a dry dressing
Answer: B
Rationale: Chest x-ray confirms proper placement and rules out pneumothorax
before use .
6. A patient is 2 days post-MI and becomes short of breath with crackles in all
lung fields. What should the nurse do first?
• A) Administer morphine
• B) Increase oxygen
• C) Place patient in high-Fowler's position
• D) Notify the provider
Answer: C
Rationale: High-Fowler's position reduces venous return and decreases
pulmonary congestion .
7. A nurse is caring for a patient with a new tracheostomy. What is the
priority nursing action?
• A) Suction every 2 hours
• B) Clean the inner cannula
• C) Ensure patency and secure airway
• D) Deflate the cuff
Answer: C
Rationale: Maintaining a patent airway is always the priority .
8. The nurse receives a lab result for a client on warfarin: INR 5.2. What
action is most appropriate?
, • A) Hold the next dose and notify provider
• B) Give vitamin K immediately
• C) Document the result
• D) Repeat the test
Answer: A
Rationale: INR above therapeutic range increases bleeding risk; notify provider
for dose adjustment .
9. Which finding requires urgent follow-up in a post-op client?
• A) Hemoglobin 12 g/dL
• B) 30 mL/hr urine output
• C) Sudden onset of chest pain and shortness of breath
• D) Pain 4/10
Answer: C
Rationale: This may indicate a pulmonary embolism, a life-threatening
complication .
10. Which task is appropriate to delegate to an unlicensed assistive personnel
(UAP)?
• A) Assessing IV site
• B) Assisting with ambulation
• C) Administering oral meds
• D) Teaching deep breathing exercises
Answer: B
Rationale: UAPs can assist with mobility under supervision, not assessment or
medication .
Clinical Practicum Questions and Correct
Answers (Verified Answers) Plus
Rationales 2025 Q&A | Instant Download
PDF – Clinical Judgment, Prioritization,
Skills, Pathophysiology & Safety
Clinical Judgment & Prioritization
1. A nurse is caring for a client post-abdominal surgery. Which assessment
finding requires immediate action?
• A) Hypoactive bowel sounds
• B) Pain level of 5/10
• C) Firm, distended abdomen
• D) Serosanguinous drainage on dressing
Answer: C
Rationale: A firm, distended abdomen may indicate internal bleeding or paralytic
ileus, requiring immediate intervention .
2. A patient is receiving IV morphine. Which nursing action has the highest
priority?
• A) Monitor for nausea
, • B) Assess for itching
• C) Check respiratory rate
• D) Evaluate pain relief
Answer: C
Rationale: Opioids like morphine can cause respiratory depression, making
respiratory assessment a priority .
3. A nurse notes that a patient’s surgical wound has eviscerated. What is the
priority nursing intervention?
• A) Call the provider
• B) Apply a dry sterile dressing
• C) Cover the wound with sterile saline-soaked gauze
• D) Reinsert the organs gently
Answer: C
Rationale: Evisceration is a medical emergency; moist gauze helps prevent tissue
drying and infection until surgery .
4. A client with COPD is on 2L nasal cannula. Which assessment would
prompt immediate action?
• A) O2 saturation of 91%
• B) Barrel chest
• C) Respiratory rate of 8/min
• D) Clubbed fingers
Answer: C
*Rationale: A RR of 8/min indicates respiratory depression, which is life-
threatening in a COPD patient .*
5. Which action should the nurse prioritize after a new central line is placed?
, • A) Begin IV fluids
• B) Obtain chest x-ray
• C) Document the procedure
• D) Apply a dry dressing
Answer: B
Rationale: Chest x-ray confirms proper placement and rules out pneumothorax
before use .
6. A patient is 2 days post-MI and becomes short of breath with crackles in all
lung fields. What should the nurse do first?
• A) Administer morphine
• B) Increase oxygen
• C) Place patient in high-Fowler's position
• D) Notify the provider
Answer: C
Rationale: High-Fowler's position reduces venous return and decreases
pulmonary congestion .
7. A nurse is caring for a patient with a new tracheostomy. What is the
priority nursing action?
• A) Suction every 2 hours
• B) Clean the inner cannula
• C) Ensure patency and secure airway
• D) Deflate the cuff
Answer: C
Rationale: Maintaining a patent airway is always the priority .
8. The nurse receives a lab result for a client on warfarin: INR 5.2. What
action is most appropriate?
, • A) Hold the next dose and notify provider
• B) Give vitamin K immediately
• C) Document the result
• D) Repeat the test
Answer: A
Rationale: INR above therapeutic range increases bleeding risk; notify provider
for dose adjustment .
9. Which finding requires urgent follow-up in a post-op client?
• A) Hemoglobin 12 g/dL
• B) 30 mL/hr urine output
• C) Sudden onset of chest pain and shortness of breath
• D) Pain 4/10
Answer: C
Rationale: This may indicate a pulmonary embolism, a life-threatening
complication .
10. Which task is appropriate to delegate to an unlicensed assistive personnel
(UAP)?
• A) Assessing IV site
• B) Assisting with ambulation
• C) Administering oral meds
• D) Teaching deep breathing exercises
Answer: B
Rationale: UAPs can assist with mobility under supervision, not assessment or
medication .
