2026 GRADED A+ EXAM
NUR 254 Exam 4: Pediatric Hematology, Oncology, and Neurosensory Nursing
Care 2026
1. A patient with chronic heart failure reports swelling in the ankles. Which intervention should
the nurse prioritize?
A) Encourage ambulation
B) Administer diuretics as ordered
C) Restrict fluids completely
D) Apply warm compresses
Answer: B) Administer diuretics as ordered
Rationale: Diuretics reduce fluid overload, which is causing the edema. Ambulation can help,
but first manage the fluid retention.
2. True or False: A patient with COPD should receive high-flow oxygen to ensure adequate
oxygenation.
Answer: False
Rationale: High-flow oxygen can depress the respiratory drive in COPD patients; oxygen should
be titrated carefully.
3. Scenario: A patient taking warfarin presents with bruising and bleeding gums. What is the
priority nursing action?
Answer: Assess INR and hold medication as per provider instructions.
Rationale: These are signs of excessive anticoagulation, which could lead to serious bleeding.
4. Which electrolyte imbalance is most commonly associated with loop diuretics?
A) Hyperkalemia
B) Hypokalemia
C) Hypernatremia
D) Hypocalcemia
,2026 GRADED A+ EXAM
Answer: B) Hypokalemia
Rationale: Loop diuretics cause potassium loss, so monitoring K⁺ is essential.
5. True or False: Administering insulin at bedtime is appropriate for all patients.
Answer: False
Rationale: Insulin timing depends on type, meal patterns, and blood glucose levels.
6. Which of the following is a priority for a patient with a nasogastric tube?
A) Encourage oral intake
B) Monitor bowel sounds
C) Check tube placement before feeding
D) Administer medications via IV
Answer: C) Check tube placement before feeding
Rationale: Ensures safety and prevents aspiration.
7. Scenario: A patient with pneumonia develops a new onset of confusion. What is the most likely
cause?
Answer: Hypoxia
Rationale: Confusion in older adults or patients with pneumonia often indicates low oxygen
levels.
8. Which lab value indicates risk for bleeding in a patient on heparin therapy?
A) INR 1.0
B) aPTT 100 seconds
C) Platelets 250,000
D) Hemoglobin 14 g/dL
Answer: B) aPTT 100 seconds
Rationale: Heparin therapy is monitored via aPTT; excessively high levels increase bleeding
risk.
, 2026 GRADED A+ EXAM
9. True or False: Morphine administration in acute myocardial infarction helps reduce pain and
myocardial oxygen demand.
Answer: True
Rationale: Morphine relieves pain and reduces sympathetic stimulation, lowering cardiac
workload.
10. Which patient is at highest risk for developing a pressure ulcer?
A) Ambulatory 25-year-old
B) Bedbound 80-year-old with diabetes
C) Post-op patient ambulating daily
D) Healthy outpatient with a cast
Answer: B) Bedbound 80-year-old with diabetes
Rationale: Immobility, age, and comorbidities increase pressure ulcer risk.
11. Scenario: A patient with hypoglycemia (blood glucose 45 mg/dL) is unconscious. Which is the
priority intervention?
Answer: Administer IV dextrose (D50)
Rationale: Unconscious patients cannot take oral glucose safely; IV dextrose rapidly raises
blood sugar.
12. True or False: A potassium level of 6.2 mEq/L is considered normal.
Answer: False
Rationale: Normal potassium is 3.5–5.0 mEq/L; 6.2 is hyperkalemia and potentially life-
threatening.
13. Which nursing intervention prevents aspiration in a patient with dysphagia?
A) Feed patient quickly
B) Keep patient supine
C) Provide small, thickened bites
D) Offer thin liquids only
NUR 254 Exam 4: Pediatric Hematology, Oncology, and Neurosensory Nursing
Care 2026
1. A patient with chronic heart failure reports swelling in the ankles. Which intervention should
the nurse prioritize?
A) Encourage ambulation
B) Administer diuretics as ordered
C) Restrict fluids completely
D) Apply warm compresses
Answer: B) Administer diuretics as ordered
Rationale: Diuretics reduce fluid overload, which is causing the edema. Ambulation can help,
but first manage the fluid retention.
2. True or False: A patient with COPD should receive high-flow oxygen to ensure adequate
oxygenation.
Answer: False
Rationale: High-flow oxygen can depress the respiratory drive in COPD patients; oxygen should
be titrated carefully.
3. Scenario: A patient taking warfarin presents with bruising and bleeding gums. What is the
priority nursing action?
Answer: Assess INR and hold medication as per provider instructions.
Rationale: These are signs of excessive anticoagulation, which could lead to serious bleeding.
4. Which electrolyte imbalance is most commonly associated with loop diuretics?
A) Hyperkalemia
B) Hypokalemia
C) Hypernatremia
D) Hypocalcemia
,2026 GRADED A+ EXAM
Answer: B) Hypokalemia
Rationale: Loop diuretics cause potassium loss, so monitoring K⁺ is essential.
5. True or False: Administering insulin at bedtime is appropriate for all patients.
Answer: False
Rationale: Insulin timing depends on type, meal patterns, and blood glucose levels.
6. Which of the following is a priority for a patient with a nasogastric tube?
A) Encourage oral intake
B) Monitor bowel sounds
C) Check tube placement before feeding
D) Administer medications via IV
Answer: C) Check tube placement before feeding
Rationale: Ensures safety and prevents aspiration.
7. Scenario: A patient with pneumonia develops a new onset of confusion. What is the most likely
cause?
Answer: Hypoxia
Rationale: Confusion in older adults or patients with pneumonia often indicates low oxygen
levels.
8. Which lab value indicates risk for bleeding in a patient on heparin therapy?
A) INR 1.0
B) aPTT 100 seconds
C) Platelets 250,000
D) Hemoglobin 14 g/dL
Answer: B) aPTT 100 seconds
Rationale: Heparin therapy is monitored via aPTT; excessively high levels increase bleeding
risk.
, 2026 GRADED A+ EXAM
9. True or False: Morphine administration in acute myocardial infarction helps reduce pain and
myocardial oxygen demand.
Answer: True
Rationale: Morphine relieves pain and reduces sympathetic stimulation, lowering cardiac
workload.
10. Which patient is at highest risk for developing a pressure ulcer?
A) Ambulatory 25-year-old
B) Bedbound 80-year-old with diabetes
C) Post-op patient ambulating daily
D) Healthy outpatient with a cast
Answer: B) Bedbound 80-year-old with diabetes
Rationale: Immobility, age, and comorbidities increase pressure ulcer risk.
11. Scenario: A patient with hypoglycemia (blood glucose 45 mg/dL) is unconscious. Which is the
priority intervention?
Answer: Administer IV dextrose (D50)
Rationale: Unconscious patients cannot take oral glucose safely; IV dextrose rapidly raises
blood sugar.
12. True or False: A potassium level of 6.2 mEq/L is considered normal.
Answer: False
Rationale: Normal potassium is 3.5–5.0 mEq/L; 6.2 is hyperkalemia and potentially life-
threatening.
13. Which nursing intervention prevents aspiration in a patient with dysphagia?
A) Feed patient quickly
B) Keep patient supine
C) Provide small, thickened bites
D) Offer thin liquids only
