Latest NUR 242 Exam verified with correct answers plus rationales 2026/2027
version
1. A nurse is assessing a client who reports sudden shortness of breath. Which assessment
should the nurse perform first?
A. Pain assessment
B. Airway and breathing assessment
C. Dietary assessment
D. Psychosocial assessment
Answer: B. Airway and breathing assessment
Rationale: Airway and breathing are immediate priorities according to the ABC approach.
2. A client has a respiratory rate of 8/min and is difficult to arouse. Which action is the
priority?
A. Document the finding
B. Assess oxygenation and airway immediately
C. Offer oral fluids
D. Encourage ambulation
Answer: B. Assess oxygenation and airway immediately
Rationale: Bradypnea with decreased consciousness can indicate respiratory compromise and
requires immediate assessment.
3. Which finding is most concerning in a postoperative client?
A. Pain rated 4/10
B. Temperature of 37.4°C (99.3°F)
C. Sudden shortness of breath
D. Mild incisional tenderness
Answer: C. Sudden shortness of breath
Rationale: Sudden dyspnea may indicate a life-threatening complication such as pulmonary
embolism.
,4. A client reports pain of 8/10. What should the nurse do first?
A. Tell the client that pain is expected
B. Assess the pain characteristics
C. Administer medication without assessment
D. Encourage sleep
Answer: B. Assess the pain characteristics
Rationale: Pain should be assessed for location, quality, severity, timing, aggravating factors,
and associated symptoms before intervention.
5. Which finding is most consistent with fluid volume deficit?
A. Peripheral edema
B. Crackles
C. Orthostatic hypotension
D. Bounding pulse
Answer: C. Orthostatic hypotension
Rationale: Fluid volume deficit can cause decreased circulating volume, resulting in orthostatic
hypotension, tachycardia, dry mucous membranes, and decreased urine output.
6. Which finding is most consistent with fluid volume excess?
A. Dry mucous membranes
B. Weight loss
C. Crackles and peripheral edema
D. Poor skin turgor
Answer: C. Crackles and peripheral edema
Rationale: Excess fluid can accumulate in the lungs and peripheral tissues.
7. A client has a potassium level of 2.8 mEq/L. Which finding should the nurse anticipate?
A. Muscle weakness
B. Peaked T waves
,C. Severe flushing
D. Increased deep tendon reflexes
Answer: A. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, constipation, and cardiac
dysrhythmias.
8. Which ECG finding is associated with hyperkalemia?
A. U waves
B. Peaked T waves
C. Prolonged PR only
D. Normal ECG
Answer: B. Peaked T waves
Rationale: Tall, peaked T waves are a classic early ECG manifestation of hyperkalemia.
9. A client has a sodium level of 120 mEq/L. Which finding requires immediate attention?
A. Mild thirst
B. Seizure
C. Increased appetite
D. Dry skin
Answer: B. Seizure
Rationale: Severe hyponatremia can cause cerebral edema, confusion, seizures, and coma.
10. Which finding is expected with hypernatremia?
A. Confusion and intense thirst
B. Seizures caused by cerebral edema from water excess
C. Moist mucous membranes
D. Bradycardia as the defining feature
Answer: A. Confusion and intense thirst
, Rationale: Hypernatremia commonly causes cellular dehydration, thirst, restlessness, and
neurologic changes.
Acid-Base Balance
11. A client has the following ABG results: pH 7.28, PaCO₂ 52 mm Hg, HCO₃⁻ 24 mEq/L.
How should the nurse interpret these results?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A. Respiratory acidosis
Rationale: The pH is low and PaCO₂ is elevated, indicating respiratory acidosis.
12. A client is hyperventilating because of severe anxiety. Which acid-base imbalance can
develop?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: B. Respiratory alkalosis
Rationale: Excessive ventilation causes excessive carbon dioxide elimination, resulting in
respiratory alkalosis.
13. Which condition can cause metabolic acidosis?
A. Prolonged vomiting
B. Diabetic ketoacidosis
C. Hyperventilation
D. Excessive antacid use
Answer: B. Diabetic ketoacidosis
Rationale: DKA causes accumulation of ketone acids, resulting in metabolic acidosis.
version
1. A nurse is assessing a client who reports sudden shortness of breath. Which assessment
should the nurse perform first?
A. Pain assessment
B. Airway and breathing assessment
C. Dietary assessment
D. Psychosocial assessment
Answer: B. Airway and breathing assessment
Rationale: Airway and breathing are immediate priorities according to the ABC approach.
2. A client has a respiratory rate of 8/min and is difficult to arouse. Which action is the
priority?
A. Document the finding
B. Assess oxygenation and airway immediately
C. Offer oral fluids
D. Encourage ambulation
Answer: B. Assess oxygenation and airway immediately
Rationale: Bradypnea with decreased consciousness can indicate respiratory compromise and
requires immediate assessment.
3. Which finding is most concerning in a postoperative client?
A. Pain rated 4/10
B. Temperature of 37.4°C (99.3°F)
C. Sudden shortness of breath
D. Mild incisional tenderness
Answer: C. Sudden shortness of breath
Rationale: Sudden dyspnea may indicate a life-threatening complication such as pulmonary
embolism.
,4. A client reports pain of 8/10. What should the nurse do first?
A. Tell the client that pain is expected
B. Assess the pain characteristics
C. Administer medication without assessment
D. Encourage sleep
Answer: B. Assess the pain characteristics
Rationale: Pain should be assessed for location, quality, severity, timing, aggravating factors,
and associated symptoms before intervention.
5. Which finding is most consistent with fluid volume deficit?
A. Peripheral edema
B. Crackles
C. Orthostatic hypotension
D. Bounding pulse
Answer: C. Orthostatic hypotension
Rationale: Fluid volume deficit can cause decreased circulating volume, resulting in orthostatic
hypotension, tachycardia, dry mucous membranes, and decreased urine output.
6. Which finding is most consistent with fluid volume excess?
A. Dry mucous membranes
B. Weight loss
C. Crackles and peripheral edema
D. Poor skin turgor
Answer: C. Crackles and peripheral edema
Rationale: Excess fluid can accumulate in the lungs and peripheral tissues.
7. A client has a potassium level of 2.8 mEq/L. Which finding should the nurse anticipate?
A. Muscle weakness
B. Peaked T waves
,C. Severe flushing
D. Increased deep tendon reflexes
Answer: A. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, constipation, and cardiac
dysrhythmias.
8. Which ECG finding is associated with hyperkalemia?
A. U waves
B. Peaked T waves
C. Prolonged PR only
D. Normal ECG
Answer: B. Peaked T waves
Rationale: Tall, peaked T waves are a classic early ECG manifestation of hyperkalemia.
9. A client has a sodium level of 120 mEq/L. Which finding requires immediate attention?
A. Mild thirst
B. Seizure
C. Increased appetite
D. Dry skin
Answer: B. Seizure
Rationale: Severe hyponatremia can cause cerebral edema, confusion, seizures, and coma.
10. Which finding is expected with hypernatremia?
A. Confusion and intense thirst
B. Seizures caused by cerebral edema from water excess
C. Moist mucous membranes
D. Bradycardia as the defining feature
Answer: A. Confusion and intense thirst
, Rationale: Hypernatremia commonly causes cellular dehydration, thirst, restlessness, and
neurologic changes.
Acid-Base Balance
11. A client has the following ABG results: pH 7.28, PaCO₂ 52 mm Hg, HCO₃⁻ 24 mEq/L.
How should the nurse interpret these results?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A. Respiratory acidosis
Rationale: The pH is low and PaCO₂ is elevated, indicating respiratory acidosis.
12. A client is hyperventilating because of severe anxiety. Which acid-base imbalance can
develop?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: B. Respiratory alkalosis
Rationale: Excessive ventilation causes excessive carbon dioxide elimination, resulting in
respiratory alkalosis.
13. Which condition can cause metabolic acidosis?
A. Prolonged vomiting
B. Diabetic ketoacidosis
C. Hyperventilation
D. Excessive antacid use
Answer: B. Diabetic ketoacidosis
Rationale: DKA causes accumulation of ketone acids, resulting in metabolic acidosis.
