NUR 254 EXAM 3 QUESTIONS AND
100% VERIFIED ANSWERS WITH
RATIONALES GRADED A+ LATEST
GALEN COLLEGE OF NURSING
1. A nurse is caring for a patient with chronic obstructive pulmonary disease
(COPD) who reports increasing dyspnea. Which intervention should the nurse
implement first?
A. Administer a prescribed bronchodilator
B. Place the patient in high Fowler’s position
C. Encourage deep breathing and coughing exercises
D. Initiate oxygen therapy at 6 L/min
Answer: B
Rationale: Placing the patient in high Fowler’s position promotes lung expansion
and eases breathing. Oxygen therapy and bronchodilators may follow based on
assessment and prescription.
2. A patient with heart failure presents with sudden weight gain of 3 kg in 2 days,
dyspnea, and peripheral edema. Which action should the nurse take first?
A. Notify the provider immediately
B. Administer a diuretic as prescribed
C. Encourage fluid restriction
D. Assess vital signs and oxygen saturation
Answer: D
Rationale: Rapid assessment of vital signs and oxygenation is critical to identify
potential decompensation. Interventions follow assessment findings.
,3. A nurse is teaching a patient with newly diagnosed type 2 diabetes about self-
monitoring of blood glucose. Which statement by the patient indicates
understanding?
A. “I should check my blood sugar only when I feel symptoms.”
B. “I should record my blood glucose results daily and bring them to my
appointments.”
C. “I can skip testing if I am on oral medications.”
D. “I only need to test my glucose at bedtime.”
Answer: B
Rationale: Daily monitoring helps manage diabetes and detect hyperglycemia or
hypoglycemia. Testing only during symptoms or at a single time is inadequate.
4. A patient is receiving morphine via PCA (patient-controlled analgesia). Which
parameter requires immediate nursing intervention?
A. Patient presses the PCA button every 2 hours
B. Respiratory rate is 8 breaths per minute
C. Patient reports pain level 4/10
D. Patient expresses fear of addiction
Answer: B
Rationale: Respiratory depression is a life-threatening complication of opioid
therapy and requires immediate intervention.
5. A patient with a stage II pressure ulcer on the sacrum has a dressing that is
saturated with serosanguinous drainage. Which dressing is most appropriate?
A. Hydrocolloid
B. Transparent film
C. Foam dressing
D. Dry gauze
Answer: C
Rationale: Foam dressings absorb moderate exudate while protecting tissue from
further injury. Hydrocolloid is better for minimal drainage.
,6. A nurse is providing discharge teaching to a patient starting warfarin therapy.
Which statement indicates a need for further teaching?
A. “I will use a soft-bristle toothbrush to prevent bleeding gums.”
B. “I should maintain a consistent intake of green leafy vegetables.”
C. “I can take over-the-counter aspirin for headaches.”
D. “I will report any unusual bruising or nosebleeds.”
Answer: C
Rationale: Aspirin increases the risk of bleeding when taken with warfarin and
should be avoided unless prescribed.
7. A patient with chronic kidney disease has a serum potassium level of 6.0 mEq/L.
Which intervention should the nurse anticipate?
A. Administer potassium supplements
B. Prepare for hemodialysis
C. Encourage high-potassium foods
D. Monitor for hypokalemia
Answer: B
Rationale: Hyperkalemia can be life-threatening. Hemodialysis may be required to
reduce potassium levels safely.
8. A patient with a tracheostomy develops sudden respiratory distress and thick
secretions. What is the nurse’s priority action?
A. Suction the tracheostomy
B. Call respiratory therapy
C. Increase oxygen flow
D. Reposition the patient
Answer: A
Rationale: Suctioning removes secretions and immediately improves airway
patency and oxygenation.
, 9. A nurse is caring for a patient with acute pancreatitis. Which lab value is most
indicative of this condition?
A. Elevated serum amylase and lipase
B. Decreased white blood cell count
C. Elevated hemoglobin
D. Decreased liver enzymes
Answer: A
Rationale: Elevated amylase and lipase are hallmark indicators of acute
pancreatitis.
10. A patient with heart failure is prescribed furosemide 40 mg IV. Which
assessment finding requires immediate action before administration?
A. Blood pressure 120/80 mmHg
B. Potassium 2.8 mEq/L
C. Heart rate 88 bpm
D. Weight increase of 1 kg
Answer: B
Rationale: Hypokalemia increases the risk of arrhythmias when administering
loop diuretics. Potassium correction may be required first.
11. A patient on a nasogastric tube reports nausea and abdominal distention. What
is the nurse’s first action?
A. Irrigate the tube
B. Assess tube placement
C. Notify the provider
D. Administer antiemetic
Answer: B
Rationale: Correct tube placement must be verified before any intervention to
prevent complications like aspiration.
100% VERIFIED ANSWERS WITH
RATIONALES GRADED A+ LATEST
GALEN COLLEGE OF NURSING
1. A nurse is caring for a patient with chronic obstructive pulmonary disease
(COPD) who reports increasing dyspnea. Which intervention should the nurse
implement first?
A. Administer a prescribed bronchodilator
B. Place the patient in high Fowler’s position
C. Encourage deep breathing and coughing exercises
D. Initiate oxygen therapy at 6 L/min
Answer: B
Rationale: Placing the patient in high Fowler’s position promotes lung expansion
and eases breathing. Oxygen therapy and bronchodilators may follow based on
assessment and prescription.
2. A patient with heart failure presents with sudden weight gain of 3 kg in 2 days,
dyspnea, and peripheral edema. Which action should the nurse take first?
A. Notify the provider immediately
B. Administer a diuretic as prescribed
C. Encourage fluid restriction
D. Assess vital signs and oxygen saturation
Answer: D
Rationale: Rapid assessment of vital signs and oxygenation is critical to identify
potential decompensation. Interventions follow assessment findings.
,3. A nurse is teaching a patient with newly diagnosed type 2 diabetes about self-
monitoring of blood glucose. Which statement by the patient indicates
understanding?
A. “I should check my blood sugar only when I feel symptoms.”
B. “I should record my blood glucose results daily and bring them to my
appointments.”
C. “I can skip testing if I am on oral medications.”
D. “I only need to test my glucose at bedtime.”
Answer: B
Rationale: Daily monitoring helps manage diabetes and detect hyperglycemia or
hypoglycemia. Testing only during symptoms or at a single time is inadequate.
4. A patient is receiving morphine via PCA (patient-controlled analgesia). Which
parameter requires immediate nursing intervention?
A. Patient presses the PCA button every 2 hours
B. Respiratory rate is 8 breaths per minute
C. Patient reports pain level 4/10
D. Patient expresses fear of addiction
Answer: B
Rationale: Respiratory depression is a life-threatening complication of opioid
therapy and requires immediate intervention.
5. A patient with a stage II pressure ulcer on the sacrum has a dressing that is
saturated with serosanguinous drainage. Which dressing is most appropriate?
A. Hydrocolloid
B. Transparent film
C. Foam dressing
D. Dry gauze
Answer: C
Rationale: Foam dressings absorb moderate exudate while protecting tissue from
further injury. Hydrocolloid is better for minimal drainage.
,6. A nurse is providing discharge teaching to a patient starting warfarin therapy.
Which statement indicates a need for further teaching?
A. “I will use a soft-bristle toothbrush to prevent bleeding gums.”
B. “I should maintain a consistent intake of green leafy vegetables.”
C. “I can take over-the-counter aspirin for headaches.”
D. “I will report any unusual bruising or nosebleeds.”
Answer: C
Rationale: Aspirin increases the risk of bleeding when taken with warfarin and
should be avoided unless prescribed.
7. A patient with chronic kidney disease has a serum potassium level of 6.0 mEq/L.
Which intervention should the nurse anticipate?
A. Administer potassium supplements
B. Prepare for hemodialysis
C. Encourage high-potassium foods
D. Monitor for hypokalemia
Answer: B
Rationale: Hyperkalemia can be life-threatening. Hemodialysis may be required to
reduce potassium levels safely.
8. A patient with a tracheostomy develops sudden respiratory distress and thick
secretions. What is the nurse’s priority action?
A. Suction the tracheostomy
B. Call respiratory therapy
C. Increase oxygen flow
D. Reposition the patient
Answer: A
Rationale: Suctioning removes secretions and immediately improves airway
patency and oxygenation.
, 9. A nurse is caring for a patient with acute pancreatitis. Which lab value is most
indicative of this condition?
A. Elevated serum amylase and lipase
B. Decreased white blood cell count
C. Elevated hemoglobin
D. Decreased liver enzymes
Answer: A
Rationale: Elevated amylase and lipase are hallmark indicators of acute
pancreatitis.
10. A patient with heart failure is prescribed furosemide 40 mg IV. Which
assessment finding requires immediate action before administration?
A. Blood pressure 120/80 mmHg
B. Potassium 2.8 mEq/L
C. Heart rate 88 bpm
D. Weight increase of 1 kg
Answer: B
Rationale: Hypokalemia increases the risk of arrhythmias when administering
loop diuretics. Potassium correction may be required first.
11. A patient on a nasogastric tube reports nausea and abdominal distention. What
is the nurse’s first action?
A. Irrigate the tube
B. Assess tube placement
C. Notify the provider
D. Administer antiemetic
Answer: B
Rationale: Correct tube placement must be verified before any intervention to
prevent complications like aspiration.
