HONDROS NUR 212 Practice Exam 2
Questions and Answers with Rationales
Latest Versions
1. A nurse is assessing a patient who reports sudden onset of shortness of breath.
Which assessment should the nurse perform first?
A. Pain history
B. Airway and respiratory status
C. Dietary history
D. Bowel pattern
Answer: B. Airway and respiratory status
Rationale: Acute shortness of breath may indicate a life-threatening respiratory
problem. The nurse should immediately assess airway patency, respiratory effort,
oxygen saturation, and other signs of respiratory compromise.
2. A patient has an oxygen saturation of 82% and is visibly struggling to breathe.
What is the priority nursing action?
A. Document the finding
B. Assess airway and provide appropriate oxygen support
C. Offer oral fluids
D. Ask about the patient's sleep pattern
Answer: B. Assess airway and provide appropriate oxygen support
Rationale: Severe hypoxemia and respiratory distress require immediate
intervention. Airway and breathing take priority over documentation and routine
assessment.
3. A patient with asthma reports increasing chest tightness despite using a
prescribed rescue inhaler. Which finding is most concerning?
,A. Mild anxiety
B. Ability to speak normally
C. Increasing difficulty speaking because of dyspnea
D. Mild cough
Answer: C. Increasing difficulty speaking because of dyspnea
Rationale: Difficulty speaking because of severe dyspnea suggests significant
airflow obstruction and respiratory compromise. The patient requires prompt
assessment and treatment.
4. Which finding is associated with hypoxemia?
A. Restlessness and confusion
B. Increased appetite
C. Warm, dry skin only
D. Increased urine output
Answer: A. Restlessness and confusion
Rationale: Early hypoxemia may cause restlessness, anxiety, tachycardia, and
confusion. Severe hypoxemia can progress to cyanosis, decreased consciousness,
and cardiovascular instability.
5. A patient with COPD is receiving prescribed oxygen therapy. Which action is
appropriate?
A. Monitor oxygen saturation and respiratory status
B. Automatically increase oxygen to the maximum flow rate
C. Discontinue oxygen whenever the patient eats
D. Avoid monitoring respiratory effort
Answer: A. Monitor oxygen saturation and respiratory status
Rationale: Oxygen should be administered according to the prescribed target and
the patient's clinical condition. The nurse should monitor oxygenation, respiratory
effort, and mental status.
,6. A patient with pneumonia has a temperature of 39°C (102.2°F), respiratory rate
of 30/min, and increasing confusion. Which complication should the nurse
suspect?
A. Possible sepsis
B. Constipation
C. Stable infection
D. Mild dehydration only
Answer: A. Possible sepsis
Rationale: Infection accompanied by tachypnea, fever, and altered mental status
can indicate systemic infection and possible sepsis. Prompt assessment and
escalation are required.
7. Which finding is most concerning for septic shock?
A. Persistent hypotension despite appropriate fluid resuscitation
B. Normal blood pressure
C. Normal mental status
D. Improved urine output
Answer: A. Persistent hypotension despite appropriate fluid resuscitation
Rationale: Persistent hypotension despite adequate fluid resuscitation is
characteristic of severe circulatory dysfunction associated with septic shock and
requires urgent management.
8. A patient with suspected sepsis has a urine output of 15 mL/hr. What does this
finding suggest?
A. Adequate renal perfusion
B. Possible decreased organ perfusion
C. Improved kidney function
D. Normal urine production
, Answer: B. Possible decreased organ perfusion
Rationale: Low urine output can occur when renal perfusion is reduced. In a
patient with suspected sepsis, oliguria can be a sign of organ dysfunction and
requires prompt assessment.
9. A patient with heart failure reports increasing shortness of breath when lying
flat. Which term describes this symptom?
A. Orthopnea
B. Dysuria
C. Hematemesis
D. Hematuria
Answer: A. Orthopnea
Rationale: Orthopnea is difficulty breathing when lying flat. It is commonly
associated with pulmonary congestion in heart failure.
10. Which finding is most consistent with worsening left-sided heart failure?
A. Pulmonary crackles
B. Increased appetite
C. Dry mucous membranes
D. Decreased respiratory rate without symptoms
Answer: A. Pulmonary crackles
Rationale: Left-sided heart failure can cause pulmonary vascular congestion and
fluid accumulation in the lungs, producing crackles, dyspnea, orthopnea, and
pulmonary edema.
11. A patient with heart failure has gained 2.5 kg (5.5 lb) in several days. What
should the nurse suspect?
Questions and Answers with Rationales
Latest Versions
1. A nurse is assessing a patient who reports sudden onset of shortness of breath.
Which assessment should the nurse perform first?
A. Pain history
B. Airway and respiratory status
C. Dietary history
D. Bowel pattern
Answer: B. Airway and respiratory status
Rationale: Acute shortness of breath may indicate a life-threatening respiratory
problem. The nurse should immediately assess airway patency, respiratory effort,
oxygen saturation, and other signs of respiratory compromise.
2. A patient has an oxygen saturation of 82% and is visibly struggling to breathe.
What is the priority nursing action?
A. Document the finding
B. Assess airway and provide appropriate oxygen support
C. Offer oral fluids
D. Ask about the patient's sleep pattern
Answer: B. Assess airway and provide appropriate oxygen support
Rationale: Severe hypoxemia and respiratory distress require immediate
intervention. Airway and breathing take priority over documentation and routine
assessment.
3. A patient with asthma reports increasing chest tightness despite using a
prescribed rescue inhaler. Which finding is most concerning?
,A. Mild anxiety
B. Ability to speak normally
C. Increasing difficulty speaking because of dyspnea
D. Mild cough
Answer: C. Increasing difficulty speaking because of dyspnea
Rationale: Difficulty speaking because of severe dyspnea suggests significant
airflow obstruction and respiratory compromise. The patient requires prompt
assessment and treatment.
4. Which finding is associated with hypoxemia?
A. Restlessness and confusion
B. Increased appetite
C. Warm, dry skin only
D. Increased urine output
Answer: A. Restlessness and confusion
Rationale: Early hypoxemia may cause restlessness, anxiety, tachycardia, and
confusion. Severe hypoxemia can progress to cyanosis, decreased consciousness,
and cardiovascular instability.
5. A patient with COPD is receiving prescribed oxygen therapy. Which action is
appropriate?
A. Monitor oxygen saturation and respiratory status
B. Automatically increase oxygen to the maximum flow rate
C. Discontinue oxygen whenever the patient eats
D. Avoid monitoring respiratory effort
Answer: A. Monitor oxygen saturation and respiratory status
Rationale: Oxygen should be administered according to the prescribed target and
the patient's clinical condition. The nurse should monitor oxygenation, respiratory
effort, and mental status.
,6. A patient with pneumonia has a temperature of 39°C (102.2°F), respiratory rate
of 30/min, and increasing confusion. Which complication should the nurse
suspect?
A. Possible sepsis
B. Constipation
C. Stable infection
D. Mild dehydration only
Answer: A. Possible sepsis
Rationale: Infection accompanied by tachypnea, fever, and altered mental status
can indicate systemic infection and possible sepsis. Prompt assessment and
escalation are required.
7. Which finding is most concerning for septic shock?
A. Persistent hypotension despite appropriate fluid resuscitation
B. Normal blood pressure
C. Normal mental status
D. Improved urine output
Answer: A. Persistent hypotension despite appropriate fluid resuscitation
Rationale: Persistent hypotension despite adequate fluid resuscitation is
characteristic of severe circulatory dysfunction associated with septic shock and
requires urgent management.
8. A patient with suspected sepsis has a urine output of 15 mL/hr. What does this
finding suggest?
A. Adequate renal perfusion
B. Possible decreased organ perfusion
C. Improved kidney function
D. Normal urine production
, Answer: B. Possible decreased organ perfusion
Rationale: Low urine output can occur when renal perfusion is reduced. In a
patient with suspected sepsis, oliguria can be a sign of organ dysfunction and
requires prompt assessment.
9. A patient with heart failure reports increasing shortness of breath when lying
flat. Which term describes this symptom?
A. Orthopnea
B. Dysuria
C. Hematemesis
D. Hematuria
Answer: A. Orthopnea
Rationale: Orthopnea is difficulty breathing when lying flat. It is commonly
associated with pulmonary congestion in heart failure.
10. Which finding is most consistent with worsening left-sided heart failure?
A. Pulmonary crackles
B. Increased appetite
C. Dry mucous membranes
D. Decreased respiratory rate without symptoms
Answer: A. Pulmonary crackles
Rationale: Left-sided heart failure can cause pulmonary vascular congestion and
fluid accumulation in the lungs, producing crackles, dyspnea, orthopnea, and
pulmonary edema.
11. A patient with heart failure has gained 2.5 kg (5.5 lb) in several days. What
should the nurse suspect?
