NUR 254
1
NUR 254 EXAM 1 GUIDE – GALEN COLLEGE OF NURSING |
2025/2026 STUDY GUIDE | LATEST UPDATE 2026/2027 |
PRACTICE QUESTIONS AND ANSWERS | EXAM REVIEW.
Table of Contents
1. Nursing Process and Clinical Judgment
2. Patient Safety and Infection Control
3. Medication Administration and Pharmacology
4. Vital Signs and Physical Assessment
5. Fluid, Electrolyte, and Acid-Base Balance
6. Perioperative and Procedural Nursing Care
7. Documentation and Informatics
8. Therapeutic Communication and Patient Education
9. Cultural Competence and Ethical Practice
10. Health Promotion and Disease Prevention
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Question 1: A nurse is caring for a patient receiving intravenous heparin therapy. The
activated partial thromboplastin time (aPTT) is 95 seconds, and the therapeutic range is 60-80
seconds. Which action should the nurse take first?
A) Continue the infusion and recheck aPTT in 6 hours
B) Stop the infusion and prepare to administer protamine sulfate
C) Reduce the infusion rate by half and notify the provider
D) Administer vitamin K subcutaneously and monitor for bleeding
Correct Answer: B) Stop the infusion and prepare to administer protamine sulfate
The aPTT of 95 seconds is significantly above the therapeutic range, indicating a high risk
for hemorrhage. Stopping the infusion immediately and preparing the antidote, protamine
sulfate, is the priority nursing action to prevent life-threatening bleeding complications.
Question 2: A patient with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 85% on room air. The provider orders oxygen at 4 L/min via nasal cannula.
What is the nurse's best action?
A) Administer the oxygen as ordered and monitor respiratory status
B) Question the order and request a lower flow rate
C) Apply a non-rebreather mask at 10 L/min instead
D) Withhold oxygen until the provider is notified
Correct Answer: B) Question the order and request a lower flow rate
Patients with COPD rely on hypoxic drive to stimulate breathing. High-flow oxygen can
suppress this drive, leading to respiratory depression. The nurse should advocate for a lower
flow rate, typically 1-2 L/min, to maintain oxygen saturation between 88-92%.
Question 3: A nurse is preparing to administer digoxin to a patient with heart failure. The
patient's apical pulse is 52 beats per minute. Which action is most appropriate?
A) Administer the medication as ordered
B) Hold the medication and notify the provider
C) Recheck the pulse in 30 minutes and administer if above 50
D) Give half the dose and document the rationale
Correct Answer: B) Hold the medication and notify the provider
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Digoxin slows the heart rate and is withheld when the apical pulse is below 60 beats per
minute in adults. Administering digoxin at this rate could precipitate bradycardia or heart
block, requiring immediate provider notification.
Question 4: A postoperative patient reports sudden shortness of breath and chest pain. Vital
signs are heart rate 118, respiratory rate 28, blood pressure 98/62, and oxygen saturation 88%
on room air. What is the nurse's priority intervention?
A) Administer prescribed pain medication
B) Apply oxygen and raise the head of the bed
C) Encourage the patient to cough and deep breathe
D) Obtain a 12-lead electrocardiogram
Correct Answer: B) Apply oxygen and raise the head of the bed
The patient's presentation suggests possible pulmonary embolism. Immediate oxygen
administration and positioning to facilitate breathing are priority interventions to address
hypoxemia while preparing for further diagnostic measures.
Question 5: A nurse is calculating the intake and output for a patient over 24 hours. Intake:
1200 mL oral fluids, 500 mL IV fluids, 250 mL ice chips. Output: 1400 mL urine, 200 mL
emesis, 150 mL wound drainage. What is the net fluid balance?
A) Positive 200 mL
B) Negative 200 mL
C) Positive 450 mL
D) Negative 450 mL
Correct Answer: A) Positive 200 mL
Total intake equals 1200 + 500 + 125 (half of ice chips) = 1825 mL. Total output equals 1400
+ 200 + 150 = 1750 mL. The net balance is 1825 - 1750 = positive 200 mL.
Question 6: A patient with a new colostomy asks the nurse how to care for the stoma. Which
statement indicates the patient needs further teaching?
A) "I should clean the stoma with mild soap and water."
B) "I will change the pouch every 7 to 10 days."
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C) "I need to measure the stoma regularly as it shrinks."
D) "I should apply the skin barrier before the pouch."
Correct Answer: B) "I will change the pouch every 7 to 10 days."
Colostomy pouches should typically be changed every 3 to 7 days, or when leakage occurs, to
prevent skin breakdown and infection. Waiting 7 to 10 days is too long and increases the risk
of peristomal skin irritation.
Question 7: A nurse is assessing a patient with suspected fluid volume deficit. Which finding
is most consistent with this condition?
A) Bounding pulse and hypertension
B) Crackles in the lung bases
C) Poor skin turgor and concentrated urine
D) Peripheral edema and weight gain
Correct Answer: C) Poor skin turgor and concentrated urine
Fluid volume deficit manifests with decreased skin elasticity, oliguria, and concentrated urine
due to the body's compensatory mechanisms. Bounding pulse, crackles, and edema are
associated with fluid volume excess.
Question 8: A patient is prescribed enoxaparin subcutaneously. Which technique should the
nurse use for administration?
A) Inject into the deltoid muscle at a 90-degree angle
B) Administer into the abdomen avoiding the umbilicus
C) Massage the site vigorously after injection
D) Aspirate before injecting to check for blood return
Correct Answer: B) Administer into the abdomen avoiding the umbilicus
Enoxaparin is administered subcutaneously into the abdominal fatty tissue, at least 2 inches
from the umbilicus. The site should not be massaged or aspirated to prevent hematoma
formation and tissue damage.
Question 9: A nurse is evaluating a patient's understanding of a low-sodium diet. Which food
choice indicates correct understanding?
1
NUR 254 EXAM 1 GUIDE – GALEN COLLEGE OF NURSING |
2025/2026 STUDY GUIDE | LATEST UPDATE 2026/2027 |
PRACTICE QUESTIONS AND ANSWERS | EXAM REVIEW.
Table of Contents
1. Nursing Process and Clinical Judgment
2. Patient Safety and Infection Control
3. Medication Administration and Pharmacology
4. Vital Signs and Physical Assessment
5. Fluid, Electrolyte, and Acid-Base Balance
6. Perioperative and Procedural Nursing Care
7. Documentation and Informatics
8. Therapeutic Communication and Patient Education
9. Cultural Competence and Ethical Practice
10. Health Promotion and Disease Prevention
, NUR 254
2
Question 1: A nurse is caring for a patient receiving intravenous heparin therapy. The
activated partial thromboplastin time (aPTT) is 95 seconds, and the therapeutic range is 60-80
seconds. Which action should the nurse take first?
A) Continue the infusion and recheck aPTT in 6 hours
B) Stop the infusion and prepare to administer protamine sulfate
C) Reduce the infusion rate by half and notify the provider
D) Administer vitamin K subcutaneously and monitor for bleeding
Correct Answer: B) Stop the infusion and prepare to administer protamine sulfate
The aPTT of 95 seconds is significantly above the therapeutic range, indicating a high risk
for hemorrhage. Stopping the infusion immediately and preparing the antidote, protamine
sulfate, is the priority nursing action to prevent life-threatening bleeding complications.
Question 2: A patient with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 85% on room air. The provider orders oxygen at 4 L/min via nasal cannula.
What is the nurse's best action?
A) Administer the oxygen as ordered and monitor respiratory status
B) Question the order and request a lower flow rate
C) Apply a non-rebreather mask at 10 L/min instead
D) Withhold oxygen until the provider is notified
Correct Answer: B) Question the order and request a lower flow rate
Patients with COPD rely on hypoxic drive to stimulate breathing. High-flow oxygen can
suppress this drive, leading to respiratory depression. The nurse should advocate for a lower
flow rate, typically 1-2 L/min, to maintain oxygen saturation between 88-92%.
Question 3: A nurse is preparing to administer digoxin to a patient with heart failure. The
patient's apical pulse is 52 beats per minute. Which action is most appropriate?
A) Administer the medication as ordered
B) Hold the medication and notify the provider
C) Recheck the pulse in 30 minutes and administer if above 50
D) Give half the dose and document the rationale
Correct Answer: B) Hold the medication and notify the provider
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Digoxin slows the heart rate and is withheld when the apical pulse is below 60 beats per
minute in adults. Administering digoxin at this rate could precipitate bradycardia or heart
block, requiring immediate provider notification.
Question 4: A postoperative patient reports sudden shortness of breath and chest pain. Vital
signs are heart rate 118, respiratory rate 28, blood pressure 98/62, and oxygen saturation 88%
on room air. What is the nurse's priority intervention?
A) Administer prescribed pain medication
B) Apply oxygen and raise the head of the bed
C) Encourage the patient to cough and deep breathe
D) Obtain a 12-lead electrocardiogram
Correct Answer: B) Apply oxygen and raise the head of the bed
The patient's presentation suggests possible pulmonary embolism. Immediate oxygen
administration and positioning to facilitate breathing are priority interventions to address
hypoxemia while preparing for further diagnostic measures.
Question 5: A nurse is calculating the intake and output for a patient over 24 hours. Intake:
1200 mL oral fluids, 500 mL IV fluids, 250 mL ice chips. Output: 1400 mL urine, 200 mL
emesis, 150 mL wound drainage. What is the net fluid balance?
A) Positive 200 mL
B) Negative 200 mL
C) Positive 450 mL
D) Negative 450 mL
Correct Answer: A) Positive 200 mL
Total intake equals 1200 + 500 + 125 (half of ice chips) = 1825 mL. Total output equals 1400
+ 200 + 150 = 1750 mL. The net balance is 1825 - 1750 = positive 200 mL.
Question 6: A patient with a new colostomy asks the nurse how to care for the stoma. Which
statement indicates the patient needs further teaching?
A) "I should clean the stoma with mild soap and water."
B) "I will change the pouch every 7 to 10 days."
, NUR 254
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C) "I need to measure the stoma regularly as it shrinks."
D) "I should apply the skin barrier before the pouch."
Correct Answer: B) "I will change the pouch every 7 to 10 days."
Colostomy pouches should typically be changed every 3 to 7 days, or when leakage occurs, to
prevent skin breakdown and infection. Waiting 7 to 10 days is too long and increases the risk
of peristomal skin irritation.
Question 7: A nurse is assessing a patient with suspected fluid volume deficit. Which finding
is most consistent with this condition?
A) Bounding pulse and hypertension
B) Crackles in the lung bases
C) Poor skin turgor and concentrated urine
D) Peripheral edema and weight gain
Correct Answer: C) Poor skin turgor and concentrated urine
Fluid volume deficit manifests with decreased skin elasticity, oliguria, and concentrated urine
due to the body's compensatory mechanisms. Bounding pulse, crackles, and edema are
associated with fluid volume excess.
Question 8: A patient is prescribed enoxaparin subcutaneously. Which technique should the
nurse use for administration?
A) Inject into the deltoid muscle at a 90-degree angle
B) Administer into the abdomen avoiding the umbilicus
C) Massage the site vigorously after injection
D) Aspirate before injecting to check for blood return
Correct Answer: B) Administer into the abdomen avoiding the umbilicus
Enoxaparin is administered subcutaneously into the abdominal fatty tissue, at least 2 inches
from the umbilicus. The site should not be massaged or aspirated to prevent hematoma
formation and tissue damage.
Question 9: A nurse is evaluating a patient's understanding of a low-sodium diet. Which food
choice indicates correct understanding?
