NUR 254 Exam 1 Actual Exam 2026/2027 – Complete Exam-Style Questions with
Detailed Rationales | 100% Verified | Pass Guaranteed – A+ Graded
Section A: Foundations of Medical-Surgical Nursing & Nursing
Process
Q1: A nurse is caring for four patients on a medical-surgical unit. Which patient should
the nurse assess FIRST?
A. A patient requesting a PRN sleeping medication
B. A patient with a blood pressure of 148/92 mmHg
C. A patient with a respiratory rate of 8/minute and shallow breathing [CORRECT]
D. A patient scheduled for discharge in 30 minutes
Correct Answer: C
Rationale: Using ABCs prioritization, the patient with respiratory depression (bradypnea,
shallow breathing) requires immediate assessment and intervention. Options A, B, and
D represent stable or non-urgent conditions that can be addressed after the
airway/breathing emergency.
Q2: A nurse delegates vital sign measurement to unlicensed assistive personnel (UAP)
for a group of stable medical-surgical patients. Which finding must the UAP report
immediately to the nurse?
A. Blood pressure 132/84 mmHg
B. Heart rate 76 beats/minute
C. Respiratory rate 8/minute and shallow [CORRECT]
,D. Temperature 99.2°F orally
Correct Answer: C
Rationale: A respiratory rate of 8/minute indicates respiratory depression, an urgent
finding requiring immediate RN assessment and intervention per ABC prioritization.
Options A, B, and D are within acceptable or non-urgent ranges.
Q3: During the implementation phase of the nursing process, a nurse administers a
prescribed diuretic to a patient with heart failure and elevates the patient's lower
extremities. The nurse then documents the interventions. Which step of the nursing
process should the nurse perform NEXT?
A. Develop a nursing diagnosis
B. Evaluate patient outcomes [CORRECT]
C. Perform a comprehensive admission assessment
D. Formulate a plan of care
Correct Answer: B
Rationale: After implementing interventions (administering medication, positioning), the
nurse evaluates the patient's response and outcomes. Options A, C, and D occur earlier
in the nursing process (ADPIE).
Q4: Which action by a medical-surgical nurse BEST demonstrates the QSEN
competency of safety?
A. Providing culturally appropriate meal choices
B. Using two patient identifiers before medication administration [CORRECT]
C. Collaborating with the physical therapist on discharge planning
, D. Reviewing current research on wound care dressings
Correct Answer: B
Rationale: Using two identifiers before medication administration directly addresses the
QSEN safety competency by preventing errors. Option A reflects patient-centered care.
Option C reflects teamwork/collaboration. Option D reflects evidence-based practice.
Q5: A nurse is using critical thinking to analyze a patient's deteriorating condition. Which
intellectual standard is the nurse applying when questioning whether the blood pressure
reading is accurate before notifying the provider?
A. Creativity
B. Confidence
C. Verification [CORRECT]
D. Perseverance
Correct Answer: C
Rationale: Verification involves confirming data accuracy before acting, a key critical
thinking standard. Options A, B, and D are other critical thinking traits but do not
specifically describe confirming data accuracy.
Q6: A nurse is caring for a patient who refuses a blood transfusion based on religious
beliefs. The nurse ensures the patient's decision is documented and respected while
providing alternative care options. This action BEST reflects which principle?
A. Paternalism
B. Patient-centered care and autonomy [CORRECT]
C. Utilitarianism
Detailed Rationales | 100% Verified | Pass Guaranteed – A+ Graded
Section A: Foundations of Medical-Surgical Nursing & Nursing
Process
Q1: A nurse is caring for four patients on a medical-surgical unit. Which patient should
the nurse assess FIRST?
A. A patient requesting a PRN sleeping medication
B. A patient with a blood pressure of 148/92 mmHg
C. A patient with a respiratory rate of 8/minute and shallow breathing [CORRECT]
D. A patient scheduled for discharge in 30 minutes
Correct Answer: C
Rationale: Using ABCs prioritization, the patient with respiratory depression (bradypnea,
shallow breathing) requires immediate assessment and intervention. Options A, B, and
D represent stable or non-urgent conditions that can be addressed after the
airway/breathing emergency.
Q2: A nurse delegates vital sign measurement to unlicensed assistive personnel (UAP)
for a group of stable medical-surgical patients. Which finding must the UAP report
immediately to the nurse?
A. Blood pressure 132/84 mmHg
B. Heart rate 76 beats/minute
C. Respiratory rate 8/minute and shallow [CORRECT]
,D. Temperature 99.2°F orally
Correct Answer: C
Rationale: A respiratory rate of 8/minute indicates respiratory depression, an urgent
finding requiring immediate RN assessment and intervention per ABC prioritization.
Options A, B, and D are within acceptable or non-urgent ranges.
Q3: During the implementation phase of the nursing process, a nurse administers a
prescribed diuretic to a patient with heart failure and elevates the patient's lower
extremities. The nurse then documents the interventions. Which step of the nursing
process should the nurse perform NEXT?
A. Develop a nursing diagnosis
B. Evaluate patient outcomes [CORRECT]
C. Perform a comprehensive admission assessment
D. Formulate a plan of care
Correct Answer: B
Rationale: After implementing interventions (administering medication, positioning), the
nurse evaluates the patient's response and outcomes. Options A, C, and D occur earlier
in the nursing process (ADPIE).
Q4: Which action by a medical-surgical nurse BEST demonstrates the QSEN
competency of safety?
A. Providing culturally appropriate meal choices
B. Using two patient identifiers before medication administration [CORRECT]
C. Collaborating with the physical therapist on discharge planning
, D. Reviewing current research on wound care dressings
Correct Answer: B
Rationale: Using two identifiers before medication administration directly addresses the
QSEN safety competency by preventing errors. Option A reflects patient-centered care.
Option C reflects teamwork/collaboration. Option D reflects evidence-based practice.
Q5: A nurse is using critical thinking to analyze a patient's deteriorating condition. Which
intellectual standard is the nurse applying when questioning whether the blood pressure
reading is accurate before notifying the provider?
A. Creativity
B. Confidence
C. Verification [CORRECT]
D. Perseverance
Correct Answer: C
Rationale: Verification involves confirming data accuracy before acting, a key critical
thinking standard. Options A, B, and D are other critical thinking traits but do not
specifically describe confirming data accuracy.
Q6: A nurse is caring for a patient who refuses a blood transfusion based on religious
beliefs. The nurse ensures the patient's decision is documented and respected while
providing alternative care options. This action BEST reflects which principle?
A. Paternalism
B. Patient-centered care and autonomy [CORRECT]
C. Utilitarianism
