Nursing 354 Comprehensive Final
Review Exam Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
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1. A nurse is assessing a client who has just returned from surgery. Which finding
requires the nurse's immediate attention?
A. Pain rated 6/10
B. Temperature of 37.4°C (99.3°F)
C. Oxygen saturation of 88%
D. Urine output of 40 mL/hr
Answer: C. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and requires
immediate assessment and intervention. Airway and breathing take priority
over pain, mild temperature elevation, and adequate urine output.
2. Which assessment finding is most consistent with rheumatoid arthritis?
A. Joint pain that improves with prolonged rest
B. Symmetric joint inflammation and morning stiffness
,C. Isolated degeneration of weight-bearing joints
D. Pain occurring only after strenuous activity
Answer: B. Symmetric joint inflammation and morning stiffness
Rationale: Rheumatoid arthritis is a systemic autoimmune disorder commonly
characterized by symmetric joint inflammation, prolonged morning stiffness,
swelling, and progressive joint damage.
3. A client with osteoarthritis asks about measures to reduce joint stress. Which
recommendation is appropriate?
A. Avoid all physical activity
B. Perform high-impact exercises daily
C. Maintain a healthy activity routine with low-impact exercise
D. Keep affected joints completely immobilized
Answer: C. Maintain a healthy activity routine with low-impact exercise
Rationale: Low-impact activities such as walking, swimming, and cycling can
improve mobility and muscle strength while reducing excessive stress on
affected joints.
4. A client with a newly applied cast reports severe pain that is not relieved by
prescribed analgesics. Which action should the nurse take first?
A. Elevate the extremity
B. Assess neurovascular status
C. Apply heat over the cast
D. Encourage increased oral fluids
Answer: B. Assess neurovascular status
Rationale: Severe, unrelieved pain may indicate impaired circulation or
compartment syndrome. Neurovascular assessment should occur promptly to
identify potentially limb-threatening complications.
,5. Which finding is most concerning in a client with a fracture?
A. Mild swelling around the injury
B. Bruising at the fracture site
C. Absent distal pulse
D. Limited range of motion
Answer: C. Absent distal pulse
Rationale: An absent distal pulse may indicate significant vascular compromise
and requires immediate intervention to prevent tissue ischemia.
6. Which intervention is most appropriate for preventing pressure injuries in an
immobile client?
A. Massage reddened areas
B. Reposition the client regularly
C. Keep the head of the bed elevated continuously
D. Use donut-shaped devices under the sacrum
Answer: B. Reposition the client regularly
Rationale: Regular repositioning relieves prolonged pressure and helps maintain
tissue perfusion. Massage of reddened areas can cause additional tissue
damage.
7. Which finding indicates a stage 2 pressure injury?
A. Intact skin with nonblanchable redness
B. Full-thickness skin loss with exposed bone
C. Partial-thickness skin loss with exposed dermis
D. Full-thickness tissue loss with visible adipose tissue
Answer: C. Partial-thickness skin loss with exposed dermis
, Rationale: A stage 2 pressure injury involves partial-thickness skin loss with
exposed dermis and does not involve exposed muscle, tendon, bone, or adipose
tissue.
8. A client with a major burn injury is admitted to the emergency department.
Which assessment has the highest priority?
A. Pain level
B. Airway patency
C. Nutritional status
D. Range of motion
Answer: B. Airway patency
Rationale: Airway assessment is the immediate priority in major burns,
particularly when inhalation injury is possible. Airway edema can progress
rapidly and compromise ventilation.
9. Which finding suggests an inhalation injury in a client with burns?
A. Blisters on the forearm
B. Hoarseness and soot around the mouth
C. Redness on the lower leg
D. Pain at the burn site
Answer: B. Hoarseness and soot around the mouth
Rationale: Hoarseness, facial burns, soot around the mouth or nose, and
respiratory changes may indicate inhalation injury and impending airway
compromise.
10. Which nursing action is appropriate when administering a high-alert
medication?
Review Exam Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
1. A nurse is assessing a client who has just returned from surgery. Which finding
requires the nurse's immediate attention?
A. Pain rated 6/10
B. Temperature of 37.4°C (99.3°F)
C. Oxygen saturation of 88%
D. Urine output of 40 mL/hr
Answer: C. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and requires
immediate assessment and intervention. Airway and breathing take priority
over pain, mild temperature elevation, and adequate urine output.
2. Which assessment finding is most consistent with rheumatoid arthritis?
A. Joint pain that improves with prolonged rest
B. Symmetric joint inflammation and morning stiffness
,C. Isolated degeneration of weight-bearing joints
D. Pain occurring only after strenuous activity
Answer: B. Symmetric joint inflammation and morning stiffness
Rationale: Rheumatoid arthritis is a systemic autoimmune disorder commonly
characterized by symmetric joint inflammation, prolonged morning stiffness,
swelling, and progressive joint damage.
3. A client with osteoarthritis asks about measures to reduce joint stress. Which
recommendation is appropriate?
A. Avoid all physical activity
B. Perform high-impact exercises daily
C. Maintain a healthy activity routine with low-impact exercise
D. Keep affected joints completely immobilized
Answer: C. Maintain a healthy activity routine with low-impact exercise
Rationale: Low-impact activities such as walking, swimming, and cycling can
improve mobility and muscle strength while reducing excessive stress on
affected joints.
4. A client with a newly applied cast reports severe pain that is not relieved by
prescribed analgesics. Which action should the nurse take first?
A. Elevate the extremity
B. Assess neurovascular status
C. Apply heat over the cast
D. Encourage increased oral fluids
Answer: B. Assess neurovascular status
Rationale: Severe, unrelieved pain may indicate impaired circulation or
compartment syndrome. Neurovascular assessment should occur promptly to
identify potentially limb-threatening complications.
,5. Which finding is most concerning in a client with a fracture?
A. Mild swelling around the injury
B. Bruising at the fracture site
C. Absent distal pulse
D. Limited range of motion
Answer: C. Absent distal pulse
Rationale: An absent distal pulse may indicate significant vascular compromise
and requires immediate intervention to prevent tissue ischemia.
6. Which intervention is most appropriate for preventing pressure injuries in an
immobile client?
A. Massage reddened areas
B. Reposition the client regularly
C. Keep the head of the bed elevated continuously
D. Use donut-shaped devices under the sacrum
Answer: B. Reposition the client regularly
Rationale: Regular repositioning relieves prolonged pressure and helps maintain
tissue perfusion. Massage of reddened areas can cause additional tissue
damage.
7. Which finding indicates a stage 2 pressure injury?
A. Intact skin with nonblanchable redness
B. Full-thickness skin loss with exposed bone
C. Partial-thickness skin loss with exposed dermis
D. Full-thickness tissue loss with visible adipose tissue
Answer: C. Partial-thickness skin loss with exposed dermis
, Rationale: A stage 2 pressure injury involves partial-thickness skin loss with
exposed dermis and does not involve exposed muscle, tendon, bone, or adipose
tissue.
8. A client with a major burn injury is admitted to the emergency department.
Which assessment has the highest priority?
A. Pain level
B. Airway patency
C. Nutritional status
D. Range of motion
Answer: B. Airway patency
Rationale: Airway assessment is the immediate priority in major burns,
particularly when inhalation injury is possible. Airway edema can progress
rapidly and compromise ventilation.
9. Which finding suggests an inhalation injury in a client with burns?
A. Blisters on the forearm
B. Hoarseness and soot around the mouth
C. Redness on the lower leg
D. Pain at the burn site
Answer: B. Hoarseness and soot around the mouth
Rationale: Hoarseness, facial burns, soot around the mouth or nose, and
respiratory changes may indicate inhalation injury and impending airway
compromise.
10. Which nursing action is appropriate when administering a high-alert
medication?
