NUR 211 Exam 2 – Comprehensive Questions and
Answers with Detailed Rationales
1. A nurse is assessing a patient who reports sudden shortness of
breath and chest discomfort. Which assessment finding requires the
nurse's immediate attention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 86%
C. Temperature of 37.1°C
D. Heart rate of 78/min
Answer: B. Oxygen saturation of 86%
Rationale: An oxygen saturation of 86% indicates significant hypoxemia
and requires prompt intervention and further assessment. The other
findings are within commonly expected adult ranges.
2. Which nursing action best demonstrates use of the nursing process?
A. Administering medication without reassessment
B. Collecting assessment data before establishing nursing priorities
C. Delegating all patient care activities to assistive personnel
D. Documenting only abnormal findings
Answer: B. Collecting assessment data before establishing nursing
priorities
Rationale: Assessment provides the information needed to identify
problems, establish nursing diagnoses, plan interventions, and evaluate
outcomes.
3. A patient is at increased risk for falls. Which intervention is most
appropriate?
A. Keep the bed in its highest position
B. Place the call light within reach
,C. Encourage the patient to ambulate independently
D. Keep all four side rails raised at all times
Answer: B. Place the call light within reach
Rationale: Easy access to the call light allows the patient to request
assistance before attempting to get out of bed. The bed should
generally be kept low, and unnecessary restraints or side rails should be
avoided.
4. Which finding most strongly suggests fluid volume deficit?
A. Peripheral edema
B. Bounding pulse
C. Orthostatic hypotension
D. Jugular venous distention
Answer: C. Orthostatic hypotension
Rationale: A decrease in blood pressure with position changes is
commonly associated with reduced circulating volume. Edema,
bounding pulses, and jugular venous distention are more consistent
with fluid excess.
5. A nurse is preparing to administer an oral medication. Which action
is essential before administration?
A. Ask another patient whether the medication is correct
B. Verify the medication against the medication administration record
C. Leave the medication at the bedside without explanation
D. Crush every medication before administration
Answer: B. Verify the medication against the medication
administration record
Rationale: Medication administration requires systematic verification
of the medication, patient, dose, route, timing, and other applicable
safety checks.
,6. Which patient should the nurse assess first?
A. Patient requesting assistance with bathing
B. Patient reporting new-onset difficulty breathing
C. Patient requesting a snack
D. Patient awaiting discharge instructions
Answer: B. Patient reporting new-onset difficulty breathing
Rationale: Airway and breathing problems take priority under the ABC
framework because deterioration can rapidly become life-threatening.
7. Which intervention best reduces the risk of healthcare-associated
infection?
A. Wearing gloves for every patient interaction
B. Performing appropriate hand hygiene
C. Using antibiotics prophylactically for all patients
D. Keeping patients isolated routinely
Answer: B. Performing appropriate hand hygiene
Rationale: Proper hand hygiene is one of the most effective methods
for preventing transmission of infectious organisms.
8. A patient has a fever and chills. Which additional finding should
concern the nurse most?
A. Heart rate of 88/min
B. Blood pressure of 118/72 mm Hg
C. New confusion and hypotension
D. Respiratory rate of 16/min
Answer: C. New confusion and hypotension
Rationale: New altered mental status combined with hypotension may
indicate systemic deterioration such as sepsis and requires immediate
assessment and intervention.
, 9. Which statement demonstrates appropriate therapeutic
communication?
A. “You shouldn't feel that way.”
B. “Everything will be fine.”
C. “Tell me more about what concerns you.”
D. “I know exactly how you feel.”
Answer: C. “Tell me more about what concerns you.”
Rationale: Open-ended statements encourage patients to express
concerns and provide additional information without imposing
judgment or false reassurance.
10. Which assessment finding is most concerning in a patient receiving
opioid analgesia?
A. Mild nausea
B. Respiratory rate of 8/min
C. Pain rating of 4/10
D. Mild constipation
Answer: B. Respiratory rate of 8/min
Rationale: Opioids can cause respiratory depression. A markedly
reduced respiratory rate requires prompt assessment and intervention.
11. Which laboratory value is most directly associated with oxygen-
carrying capacity?
A. Hemoglobin
B. Sodium
C. Creatinine
D. Albumin
Answer: A. Hemoglobin
Rationale: Hemoglobin binds and transports oxygen in the blood.
Sodium primarily reflects fluid and electrolyte balance, creatinine
Answers with Detailed Rationales
1. A nurse is assessing a patient who reports sudden shortness of
breath and chest discomfort. Which assessment finding requires the
nurse's immediate attention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 86%
C. Temperature of 37.1°C
D. Heart rate of 78/min
Answer: B. Oxygen saturation of 86%
Rationale: An oxygen saturation of 86% indicates significant hypoxemia
and requires prompt intervention and further assessment. The other
findings are within commonly expected adult ranges.
2. Which nursing action best demonstrates use of the nursing process?
A. Administering medication without reassessment
B. Collecting assessment data before establishing nursing priorities
C. Delegating all patient care activities to assistive personnel
D. Documenting only abnormal findings
Answer: B. Collecting assessment data before establishing nursing
priorities
Rationale: Assessment provides the information needed to identify
problems, establish nursing diagnoses, plan interventions, and evaluate
outcomes.
3. A patient is at increased risk for falls. Which intervention is most
appropriate?
A. Keep the bed in its highest position
B. Place the call light within reach
,C. Encourage the patient to ambulate independently
D. Keep all four side rails raised at all times
Answer: B. Place the call light within reach
Rationale: Easy access to the call light allows the patient to request
assistance before attempting to get out of bed. The bed should
generally be kept low, and unnecessary restraints or side rails should be
avoided.
4. Which finding most strongly suggests fluid volume deficit?
A. Peripheral edema
B. Bounding pulse
C. Orthostatic hypotension
D. Jugular venous distention
Answer: C. Orthostatic hypotension
Rationale: A decrease in blood pressure with position changes is
commonly associated with reduced circulating volume. Edema,
bounding pulses, and jugular venous distention are more consistent
with fluid excess.
5. A nurse is preparing to administer an oral medication. Which action
is essential before administration?
A. Ask another patient whether the medication is correct
B. Verify the medication against the medication administration record
C. Leave the medication at the bedside without explanation
D. Crush every medication before administration
Answer: B. Verify the medication against the medication
administration record
Rationale: Medication administration requires systematic verification
of the medication, patient, dose, route, timing, and other applicable
safety checks.
,6. Which patient should the nurse assess first?
A. Patient requesting assistance with bathing
B. Patient reporting new-onset difficulty breathing
C. Patient requesting a snack
D. Patient awaiting discharge instructions
Answer: B. Patient reporting new-onset difficulty breathing
Rationale: Airway and breathing problems take priority under the ABC
framework because deterioration can rapidly become life-threatening.
7. Which intervention best reduces the risk of healthcare-associated
infection?
A. Wearing gloves for every patient interaction
B. Performing appropriate hand hygiene
C. Using antibiotics prophylactically for all patients
D. Keeping patients isolated routinely
Answer: B. Performing appropriate hand hygiene
Rationale: Proper hand hygiene is one of the most effective methods
for preventing transmission of infectious organisms.
8. A patient has a fever and chills. Which additional finding should
concern the nurse most?
A. Heart rate of 88/min
B. Blood pressure of 118/72 mm Hg
C. New confusion and hypotension
D. Respiratory rate of 16/min
Answer: C. New confusion and hypotension
Rationale: New altered mental status combined with hypotension may
indicate systemic deterioration such as sepsis and requires immediate
assessment and intervention.
, 9. Which statement demonstrates appropriate therapeutic
communication?
A. “You shouldn't feel that way.”
B. “Everything will be fine.”
C. “Tell me more about what concerns you.”
D. “I know exactly how you feel.”
Answer: C. “Tell me more about what concerns you.”
Rationale: Open-ended statements encourage patients to express
concerns and provide additional information without imposing
judgment or false reassurance.
10. Which assessment finding is most concerning in a patient receiving
opioid analgesia?
A. Mild nausea
B. Respiratory rate of 8/min
C. Pain rating of 4/10
D. Mild constipation
Answer: B. Respiratory rate of 8/min
Rationale: Opioids can cause respiratory depression. A markedly
reduced respiratory rate requires prompt assessment and intervention.
11. Which laboratory value is most directly associated with oxygen-
carrying capacity?
A. Hemoglobin
B. Sodium
C. Creatinine
D. Albumin
Answer: A. Hemoglobin
Rationale: Hemoglobin binds and transports oxygen in the blood.
Sodium primarily reflects fluid and electrolyte balance, creatinine
