NR 325 EXAM 1 NEWEST ACTUAL
EXAM COMPLETE QUESTIONS AND
CORRECT DETAILED
ANSWERS/NEWEST UPDATE!!!
Course
NR 325
1. A nurse is assessing a patient who reports shortness of breath. Which assessment should
the nurse perform first?
A. Ask about dietary preferences
B. Assess airway, breathing, respiratory effort, and oxygenation
C. Obtain the patient's family history
D. Ask about the patient's occupation
Answer: B. Assess airway, breathing, respiratory effort, and oxygenation
Rationale: Airway and breathing are immediate priorities. The nurse should rapidly determine
whether the patient has impaired ventilation or oxygenation before proceeding with less urgent
assessments.
2. Which finding is most concerning in a patient experiencing respiratory distress?
A. Respiratory rate of 18/min
B. Ability to speak in complete sentences
C. Cyanosis with increasing work of breathing
D. Clear breath sounds
Answer: C. Cyanosis with increasing work of breathing
Rationale: Cyanosis and increased work of breathing can indicate significant oxygenation or
ventilation problems. Immediate assessment and intervention are required.
3. Which position generally promotes maximum lung expansion in a patient experiencing
dyspnea?
,A. High-Fowler's
B. Supine
C. Trendelenburg
D. Flat prone
Answer: A. High-Fowler's
Rationale: Elevating the head and upper body can improve diaphragmatic expansion and
reduce the work of breathing.
4. A nurse is preparing to administer medication. Which action is essential before
administration?
A. Verify the medication against the medication order and identify the patient correctly
B. Assume the medication is correct because it was prepared by another person
C. Skip allergy verification
D. Administer the medication before checking the patient's identity
Answer: A. Verify the medication against the medication order and identify the patient
correctly
Rationale: Safe medication administration requires accurate patient identification, medication
verification, assessment of allergies, and adherence to applicable medication-administration
rights.
5. Which patient should the nurse assess first?
A. Patient requesting assistance with a meal
B. Patient with new-onset chest pressure and diaphoresis
C. Patient requesting a blanket
D. Patient awaiting routine discharge instructions
Answer: B. Patient with new-onset chest pressure and diaphoresis
Rationale: New chest pressure accompanied by diaphoresis may indicate acute coronary
syndrome and represents a potentially life-threatening condition.
6. A patient's blood pressure is 84/50 mmHg, and the patient reports dizziness. What should
the nurse do first?
,A. Assess the patient and evaluate for inadequate perfusion
B. Encourage the patient to walk
C. Ignore the result
D. Give an additional antihypertensive medication
Answer: A. Assess the patient and evaluate for inadequate perfusion
Rationale: Significant hypotension with symptoms can indicate compromised circulation. The
nurse should immediately assess the patient, obtain relevant vital signs, and intervene
according to the clinical situation.
7. Which finding is most consistent with dehydration?
A. Moist mucous membranes
B. Orthostatic hypotension and concentrated urine
C. Bounding pulses with edema
D. Rapid weight gain
Answer: B. Orthostatic hypotension and concentrated urine
Rationale: Fluid volume deficit can cause orthostatic hypotension, concentrated urine, dry
mucous membranes, thirst, tachycardia, and weight loss.
8. Which assessment finding is most suggestive of fluid volume excess?
A. Peripheral edema and rapid weight gain
B. Dry mucous membranes
C. Poor skin turgor from dehydration
D. Concentrated urine
Answer: A. Peripheral edema and rapid weight gain
Rationale: Fluid volume excess commonly causes edema, weight gain, hypertension, pulmonary
congestion, and possibly crackles or dyspnea.
9. Which electrolyte imbalance can cause muscle weakness and cardiac dysrhythmias?
A. Hypokalemia
B. Normal potassium
, C. Normal sodium
D. Mildly elevated chloride
Answer: A. Hypokalemia
Rationale: Potassium is essential for neuromuscular and cardiac electrical activity. Significant
hypokalemia can cause weakness, abnormal ECG changes, and potentially dangerous
dysrhythmias.
10. A patient has a potassium level of 6.4 mEq/L with ECG changes. What is the priority?
A. Recognize the finding as potentially life-threatening and initiate urgent treatment
B. Encourage potassium-rich foods
C. Administer potassium supplements
D. Recheck the level next week
Answer: A. Recognize the finding as potentially life-threatening and initiate urgent treatment
Rationale: Severe hyperkalemia can cause conduction abnormalities and fatal dysrhythmias.
ECG changes make the situation particularly urgent.
11. Which ECG finding is commonly associated with hyperkalemia?
A. Peaked T waves
B. Sawtooth flutter waves
C. Narrowing of every QRS complex
D. Isolated prolonged PR interval only
Answer: A. Peaked T waves
Rationale: Early ECG manifestations of hyperkalemia may include tall, peaked T waves. More
severe hyperkalemia can cause progressive conduction abnormalities.
12. Which intervention is most appropriate for preventing pressure injuries in an immobile
patient?
A. Reposition regularly and reduce prolonged pressure over vulnerable areas
B. Massage reddened bony prominences vigorously
C. Keep the patient in one position
D. Avoid assessing the skin
EXAM COMPLETE QUESTIONS AND
CORRECT DETAILED
ANSWERS/NEWEST UPDATE!!!
Course
NR 325
1. A nurse is assessing a patient who reports shortness of breath. Which assessment should
the nurse perform first?
A. Ask about dietary preferences
B. Assess airway, breathing, respiratory effort, and oxygenation
C. Obtain the patient's family history
D. Ask about the patient's occupation
Answer: B. Assess airway, breathing, respiratory effort, and oxygenation
Rationale: Airway and breathing are immediate priorities. The nurse should rapidly determine
whether the patient has impaired ventilation or oxygenation before proceeding with less urgent
assessments.
2. Which finding is most concerning in a patient experiencing respiratory distress?
A. Respiratory rate of 18/min
B. Ability to speak in complete sentences
C. Cyanosis with increasing work of breathing
D. Clear breath sounds
Answer: C. Cyanosis with increasing work of breathing
Rationale: Cyanosis and increased work of breathing can indicate significant oxygenation or
ventilation problems. Immediate assessment and intervention are required.
3. Which position generally promotes maximum lung expansion in a patient experiencing
dyspnea?
,A. High-Fowler's
B. Supine
C. Trendelenburg
D. Flat prone
Answer: A. High-Fowler's
Rationale: Elevating the head and upper body can improve diaphragmatic expansion and
reduce the work of breathing.
4. A nurse is preparing to administer medication. Which action is essential before
administration?
A. Verify the medication against the medication order and identify the patient correctly
B. Assume the medication is correct because it was prepared by another person
C. Skip allergy verification
D. Administer the medication before checking the patient's identity
Answer: A. Verify the medication against the medication order and identify the patient
correctly
Rationale: Safe medication administration requires accurate patient identification, medication
verification, assessment of allergies, and adherence to applicable medication-administration
rights.
5. Which patient should the nurse assess first?
A. Patient requesting assistance with a meal
B. Patient with new-onset chest pressure and diaphoresis
C. Patient requesting a blanket
D. Patient awaiting routine discharge instructions
Answer: B. Patient with new-onset chest pressure and diaphoresis
Rationale: New chest pressure accompanied by diaphoresis may indicate acute coronary
syndrome and represents a potentially life-threatening condition.
6. A patient's blood pressure is 84/50 mmHg, and the patient reports dizziness. What should
the nurse do first?
,A. Assess the patient and evaluate for inadequate perfusion
B. Encourage the patient to walk
C. Ignore the result
D. Give an additional antihypertensive medication
Answer: A. Assess the patient and evaluate for inadequate perfusion
Rationale: Significant hypotension with symptoms can indicate compromised circulation. The
nurse should immediately assess the patient, obtain relevant vital signs, and intervene
according to the clinical situation.
7. Which finding is most consistent with dehydration?
A. Moist mucous membranes
B. Orthostatic hypotension and concentrated urine
C. Bounding pulses with edema
D. Rapid weight gain
Answer: B. Orthostatic hypotension and concentrated urine
Rationale: Fluid volume deficit can cause orthostatic hypotension, concentrated urine, dry
mucous membranes, thirst, tachycardia, and weight loss.
8. Which assessment finding is most suggestive of fluid volume excess?
A. Peripheral edema and rapid weight gain
B. Dry mucous membranes
C. Poor skin turgor from dehydration
D. Concentrated urine
Answer: A. Peripheral edema and rapid weight gain
Rationale: Fluid volume excess commonly causes edema, weight gain, hypertension, pulmonary
congestion, and possibly crackles or dyspnea.
9. Which electrolyte imbalance can cause muscle weakness and cardiac dysrhythmias?
A. Hypokalemia
B. Normal potassium
, C. Normal sodium
D. Mildly elevated chloride
Answer: A. Hypokalemia
Rationale: Potassium is essential for neuromuscular and cardiac electrical activity. Significant
hypokalemia can cause weakness, abnormal ECG changes, and potentially dangerous
dysrhythmias.
10. A patient has a potassium level of 6.4 mEq/L with ECG changes. What is the priority?
A. Recognize the finding as potentially life-threatening and initiate urgent treatment
B. Encourage potassium-rich foods
C. Administer potassium supplements
D. Recheck the level next week
Answer: A. Recognize the finding as potentially life-threatening and initiate urgent treatment
Rationale: Severe hyperkalemia can cause conduction abnormalities and fatal dysrhythmias.
ECG changes make the situation particularly urgent.
11. Which ECG finding is commonly associated with hyperkalemia?
A. Peaked T waves
B. Sawtooth flutter waves
C. Narrowing of every QRS complex
D. Isolated prolonged PR interval only
Answer: A. Peaked T waves
Rationale: Early ECG manifestations of hyperkalemia may include tall, peaked T waves. More
severe hyperkalemia can cause progressive conduction abnormalities.
12. Which intervention is most appropriate for preventing pressure injuries in an immobile
patient?
A. Reposition regularly and reduce prolonged pressure over vulnerable areas
B. Massage reddened bony prominences vigorously
C. Keep the patient in one position
D. Avoid assessing the skin
