Adult Health II (NR 325) Exam Ultimate Study Bundle:
2026-2028 Advanced NCLEX-Style Practice Questions
with Verified Answers & In-Depth Rationales |
INSTANT PDF DOWNLOAD
Q1.
A nurse is caring for a client admitted with acute myocardial infarction (MI). The client
suddenly reports severe chest pain unrelieved by nitroglycerin. Which action should the
nurse take first?
A. Administer morphine sulfate as prescribed
B. Obtain a 12-lead ECG
C. Administer oxygen via nasal cannula
D. Notify the healthcare provider
Answer: C. Administer oxygen via nasal cannula
**Rationale: In acute MI, the priority is improving oxygen delivery to ischemic myocardial
tissue. According to ABCs, oxygenation is the first priority. While ECG and medications are
important, oxygen should be administered immediately to prevent further myocardial
damage.
Q2.
A nurse is caring for a client with septic shock. Which finding indicates that the client is
progressing into the late stage of shock?
A. Warm, flushed skin
B. Bounding pulse
C. Hypotension unresponsive to fluids
D. Increased urine output
Answer: C. Hypotension unresponsive to fluids
**Rationale: Late septic shock is characterized by persistent hypotension despite fluid
, resuscitation, indicating severe circulatory failure. Early stages show warm skin and
bounding pulse, while late stages reflect poor perfusion and organ failure.
Q3.
A nurse is assessing a client with increased intracranial pressure (ICP). Which finding
requires immediate intervention?
A. Headache
B. Projectile vomiting
C. Unequal pupils
D. Restlessness
Answer: C. Unequal pupils
**Rationale: Unequal pupils indicate possible brain herniation, a life-threatening
complication of increased ICP. Immediate intervention is required to prevent irreversible
brain damage.
Q4.
A nurse is caring for a client with acute respiratory distress syndrome (ARDS). Which
assessment finding is most concerning?
A. Respiratory rate of 24/min
B. Oxygen saturation of 85% despite oxygen therapy
C. Mild anxiety
D. Use of accessory muscles
Answer: B. Oxygen saturation of 85% despite oxygen therapy
**Rationale: ARDS involves severe hypoxemia that is often refractory to oxygen therapy.
An SpO₂ of 85% indicates critical oxygenation failure and requires urgent intervention such
as mechanical ventilation.
Q5.
2026-2028 Advanced NCLEX-Style Practice Questions
with Verified Answers & In-Depth Rationales |
INSTANT PDF DOWNLOAD
Q1.
A nurse is caring for a client admitted with acute myocardial infarction (MI). The client
suddenly reports severe chest pain unrelieved by nitroglycerin. Which action should the
nurse take first?
A. Administer morphine sulfate as prescribed
B. Obtain a 12-lead ECG
C. Administer oxygen via nasal cannula
D. Notify the healthcare provider
Answer: C. Administer oxygen via nasal cannula
**Rationale: In acute MI, the priority is improving oxygen delivery to ischemic myocardial
tissue. According to ABCs, oxygenation is the first priority. While ECG and medications are
important, oxygen should be administered immediately to prevent further myocardial
damage.
Q2.
A nurse is caring for a client with septic shock. Which finding indicates that the client is
progressing into the late stage of shock?
A. Warm, flushed skin
B. Bounding pulse
C. Hypotension unresponsive to fluids
D. Increased urine output
Answer: C. Hypotension unresponsive to fluids
**Rationale: Late septic shock is characterized by persistent hypotension despite fluid
, resuscitation, indicating severe circulatory failure. Early stages show warm skin and
bounding pulse, while late stages reflect poor perfusion and organ failure.
Q3.
A nurse is assessing a client with increased intracranial pressure (ICP). Which finding
requires immediate intervention?
A. Headache
B. Projectile vomiting
C. Unequal pupils
D. Restlessness
Answer: C. Unequal pupils
**Rationale: Unequal pupils indicate possible brain herniation, a life-threatening
complication of increased ICP. Immediate intervention is required to prevent irreversible
brain damage.
Q4.
A nurse is caring for a client with acute respiratory distress syndrome (ARDS). Which
assessment finding is most concerning?
A. Respiratory rate of 24/min
B. Oxygen saturation of 85% despite oxygen therapy
C. Mild anxiety
D. Use of accessory muscles
Answer: B. Oxygen saturation of 85% despite oxygen therapy
**Rationale: ARDS involves severe hypoxemia that is often refractory to oxygen therapy.
An SpO₂ of 85% indicates critical oxygenation failure and requires urgent intervention such
as mechanical ventilation.
Q5.
