Galen College of Nursing NUR265 Exam 1 Practice Questions
1. A client with hypovolemic shock has a blood pressure of 82/48 mmHg, heart rate of
126/min, and cool, clammy skin. Which intervention should the nurse anticipate first?
A. Administer a prescribed isotonic IV fluid bolus
B. Restrict oral and IV fluids
C. Administer a potassium supplement
D. Place the client in a high-Fowler position
Answer: A
Rationale: Isotonic fluids such as normal saline or lactated Ringer's are commonly used
initially to restore circulating volume.
2. A postoperative client suddenly develops dyspnea, chest pain, tachycardia, and an oxygen
saturation of 86%. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Hypoglycemia
D. Urinary retention
Answer: B
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia are classic
findings associated with pulmonary embolism.
3. Which assessment finding is most concerning in a client receiving a blood transfusion?
A. Temperature of 98.6°F (37°C)
B. Mild thirst
C. Chills and flank pain
D. Heart rate of 78/min
Answer: C
Rationale: Chills and flank pain can indicate an acute hemolytic transfusion reaction. The
transfusion should be stopped immediately and emergency measures initiated.
4. A nurse is caring for a client with septic shock. Which finding indicates worsening tissue
perfusion?
A. Urine output of 15 mL/hr
B. Warm extremities
1. A client with hypovolemic shock has a blood pressure of 82/48 mmHg, heart rate of
126/min, and cool, clammy skin. Which intervention should the nurse anticipate first?
A. Administer a prescribed isotonic IV fluid bolus
B. Restrict oral and IV fluids
C. Administer a potassium supplement
D. Place the client in a high-Fowler position
Answer: A
Rationale: Isotonic fluids such as normal saline or lactated Ringer's are commonly used
initially to restore circulating volume.
2. A postoperative client suddenly develops dyspnea, chest pain, tachycardia, and an oxygen
saturation of 86%. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Hypoglycemia
D. Urinary retention
Answer: B
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia are classic
findings associated with pulmonary embolism.
3. Which assessment finding is most concerning in a client receiving a blood transfusion?
A. Temperature of 98.6°F (37°C)
B. Mild thirst
C. Chills and flank pain
D. Heart rate of 78/min
Answer: C
Rationale: Chills and flank pain can indicate an acute hemolytic transfusion reaction. The
transfusion should be stopped immediately and emergency measures initiated.
4. A nurse is caring for a client with septic shock. Which finding indicates worsening tissue
perfusion?
A. Urine output of 15 mL/hr
B. Warm extremities
