NURS 3251 CJE EXAM 2 EXAM -PRACTICE QUESTIONS AND
ANSWERS PLUS DETAILED RATIONALES | COMPLETE
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1. A nurse is caring for a postoperative client who suddenly becomes restless and reports
shortness of breath. The client's oxygen saturation has decreased from 97% to 88% on
room air. Which action should the nurse take first?
A. Administer the prescribed opioid analgesic
B. Apply oxygen and assess respiratory status
C. Encourage the client to ambulate
D. Obtain a routine temperature measurement
Answer: B
Rationale: Applying oxygen while immediately assessing respiratory status addresses the
client's acute oxygenation problem. Restlessness and declining oxygen saturation can be early
signs of respiratory compromise and require prompt intervention.
2. A client with heart failure reports a 2.5-kg (5.5-lb) weight gain over the past week.
Which finding is most concerning?
A. Mild fatigue after activity
B. Decreased appetite
C. Bilateral ankle edema and increasing dyspnea
D. Sleeping seven hours each night
Answer: C
Rationale: Rapid weight gain accompanied by edema and dyspnea strongly suggests fluid
retention and worsening heart failure.
3. A nurse is preparing to administer insulin to a client with diabetes mellitus. The client's
blood glucose is 54 mg/dL, and the client is awake and able to swallow. What should the
nurse do first?
A. Give a rapid-acting carbohydrate
B. Administer the scheduled insulin
,C. Restrict oral fluids
D. Recheck the glucose in two hours
Answer: A
Rationale: A conscious client who can safely swallow should receive approximately 15 g of
rapid-acting carbohydrate, followed by reassessment of blood glucose.
4. A client receiving a blood transfusion develops chills, fever, and low back pain 15
minutes after the transfusion begins. What is the nurse's priority action?
A. Slow the transfusion rate
B. Administer acetaminophen
C. Obtain a urine specimen
D. Stop the transfusion immediately
Answer: D
Rationale: Fever, chills, and back pain shortly after transfusion initiation may indicate an
acute hemolytic reaction. The transfusion must be stopped immediately.
5. A nurse is assessing a client with chronic obstructive pulmonary disease who is receiving
oxygen. Which finding requires the most immediate follow-up?
A. Respiratory rate of 20/min
B. Oxygen saturation of 91%
C. Increasing somnolence and difficulty arousing
D. Productive cough with clear sputum
Answer: C
Rationale: Increasing somnolence may indicate worsening hypercapnia or respiratory failure
and requires immediate assessment.
6. A client receiving warfarin therapy has an INR of 5.8. Which action should the nurse
anticipate?
A. Administer an additional dose of warfarin
B. Hold the medication and notify the provider
,C. Encourage foods high in vitamin K immediately
D. Administer aspirin
Answer: B
Rationale: An INR of 5.8 indicates excessive anticoagulation and increased bleeding risk.
Warfarin should be held and the prescribed management plan followed.
7. A hospitalized client suddenly develops facial drooping and weakness of the right arm.
What should the nurse do first?
A. Activate the facility's stroke response protocol
B. Give oral fluids
C. Encourage the client to walk
D. Reassess after 30 minutes
Answer: A
Rationale: Sudden facial weakness and unilateral arm weakness are stroke warning signs.
Rapid activation of the stroke response supports timely evaluation and treatment.
8. A nurse is assessing a client with suspected dehydration. Which finding best supports the
nurse's clinical judgment?
A. Bounding peripheral pulses
B. Moist mucous membranes
C. Increased urine output
D. Orthostatic hypotension and concentrated urine
Answer: D
Rationale: Orthostatic hypotension and concentrated urine are consistent with reduced
circulating volume and dehydration.
9. A client receiving an opioid analgesic has a respiratory rate of 8/min and is difficult to
arouse. Which intervention is the priority?
A. Encourage oral fluids
B. Administer the next scheduled analgesic
, C. Support ventilation and prepare to administer naloxone as prescribed
D. Place the client in a dark room
Answer: C
Rationale: Severe opioid-related respiratory depression is life-threatening. Airway and
ventilation support take priority, with naloxone used according to the clinical protocol.
10. A client with a potassium level of 6.4 mEq/L reports palpitations. Which assessment
should the nurse prioritize?
A. Cardiac rhythm
B. Appetite
C. Skin integrity
D. Bowel pattern
Answer: A
Rationale: Severe hyperkalemia can cause potentially fatal cardiac dysrhythmias, making
cardiac assessment a priority.
11. A client with pneumonia becomes increasingly confused, has a respiratory rate of
30/min, and has an oxygen saturation of 86%. Which nursing problem should be
prioritized?
A. Activity intolerance
B. Impaired gas exchange
C. Imbalanced nutrition
D. Disturbed sleep pattern
Answer: B
Rationale: Hypoxemia, tachypnea, and confusion indicate impaired oxygenation, which takes
priority over less urgent problems.
12. A nurse notices that an intravenous potassium infusion is running faster than
prescribed. What should the nurse do first?
A. Document it at the end of the shift
B. Increase the rate further
ANSWERS PLUS DETAILED RATIONALES | COMPLETE
STUDYGUIDE| GUARANTEED PASS | DOWNLOAD INSTANT
PDF 2027-2028
1. A nurse is caring for a postoperative client who suddenly becomes restless and reports
shortness of breath. The client's oxygen saturation has decreased from 97% to 88% on
room air. Which action should the nurse take first?
A. Administer the prescribed opioid analgesic
B. Apply oxygen and assess respiratory status
C. Encourage the client to ambulate
D. Obtain a routine temperature measurement
Answer: B
Rationale: Applying oxygen while immediately assessing respiratory status addresses the
client's acute oxygenation problem. Restlessness and declining oxygen saturation can be early
signs of respiratory compromise and require prompt intervention.
2. A client with heart failure reports a 2.5-kg (5.5-lb) weight gain over the past week.
Which finding is most concerning?
A. Mild fatigue after activity
B. Decreased appetite
C. Bilateral ankle edema and increasing dyspnea
D. Sleeping seven hours each night
Answer: C
Rationale: Rapid weight gain accompanied by edema and dyspnea strongly suggests fluid
retention and worsening heart failure.
3. A nurse is preparing to administer insulin to a client with diabetes mellitus. The client's
blood glucose is 54 mg/dL, and the client is awake and able to swallow. What should the
nurse do first?
A. Give a rapid-acting carbohydrate
B. Administer the scheduled insulin
,C. Restrict oral fluids
D. Recheck the glucose in two hours
Answer: A
Rationale: A conscious client who can safely swallow should receive approximately 15 g of
rapid-acting carbohydrate, followed by reassessment of blood glucose.
4. A client receiving a blood transfusion develops chills, fever, and low back pain 15
minutes after the transfusion begins. What is the nurse's priority action?
A. Slow the transfusion rate
B. Administer acetaminophen
C. Obtain a urine specimen
D. Stop the transfusion immediately
Answer: D
Rationale: Fever, chills, and back pain shortly after transfusion initiation may indicate an
acute hemolytic reaction. The transfusion must be stopped immediately.
5. A nurse is assessing a client with chronic obstructive pulmonary disease who is receiving
oxygen. Which finding requires the most immediate follow-up?
A. Respiratory rate of 20/min
B. Oxygen saturation of 91%
C. Increasing somnolence and difficulty arousing
D. Productive cough with clear sputum
Answer: C
Rationale: Increasing somnolence may indicate worsening hypercapnia or respiratory failure
and requires immediate assessment.
6. A client receiving warfarin therapy has an INR of 5.8. Which action should the nurse
anticipate?
A. Administer an additional dose of warfarin
B. Hold the medication and notify the provider
,C. Encourage foods high in vitamin K immediately
D. Administer aspirin
Answer: B
Rationale: An INR of 5.8 indicates excessive anticoagulation and increased bleeding risk.
Warfarin should be held and the prescribed management plan followed.
7. A hospitalized client suddenly develops facial drooping and weakness of the right arm.
What should the nurse do first?
A. Activate the facility's stroke response protocol
B. Give oral fluids
C. Encourage the client to walk
D. Reassess after 30 minutes
Answer: A
Rationale: Sudden facial weakness and unilateral arm weakness are stroke warning signs.
Rapid activation of the stroke response supports timely evaluation and treatment.
8. A nurse is assessing a client with suspected dehydration. Which finding best supports the
nurse's clinical judgment?
A. Bounding peripheral pulses
B. Moist mucous membranes
C. Increased urine output
D. Orthostatic hypotension and concentrated urine
Answer: D
Rationale: Orthostatic hypotension and concentrated urine are consistent with reduced
circulating volume and dehydration.
9. A client receiving an opioid analgesic has a respiratory rate of 8/min and is difficult to
arouse. Which intervention is the priority?
A. Encourage oral fluids
B. Administer the next scheduled analgesic
, C. Support ventilation and prepare to administer naloxone as prescribed
D. Place the client in a dark room
Answer: C
Rationale: Severe opioid-related respiratory depression is life-threatening. Airway and
ventilation support take priority, with naloxone used according to the clinical protocol.
10. A client with a potassium level of 6.4 mEq/L reports palpitations. Which assessment
should the nurse prioritize?
A. Cardiac rhythm
B. Appetite
C. Skin integrity
D. Bowel pattern
Answer: A
Rationale: Severe hyperkalemia can cause potentially fatal cardiac dysrhythmias, making
cardiac assessment a priority.
11. A client with pneumonia becomes increasingly confused, has a respiratory rate of
30/min, and has an oxygen saturation of 86%. Which nursing problem should be
prioritized?
A. Activity intolerance
B. Impaired gas exchange
C. Imbalanced nutrition
D. Disturbed sleep pattern
Answer: B
Rationale: Hypoxemia, tachypnea, and confusion indicate impaired oxygenation, which takes
priority over less urgent problems.
12. A nurse notices that an intravenous potassium infusion is running faster than
prescribed. What should the nurse do first?
A. Document it at the end of the shift
B. Increase the rate further
