NUR 254 Exams 1–4 LATEST 2026/2027 VERSION WITH RATIONALES A+
GRADED
1. A nurse assesses a client admitted with community-acquired pneumonia. Which
assessment finding requires immediate intervention?
A. Temperature of 101.8°F (38.8°C)
B. Productive cough with yellow sputum
C. Oxygen saturation of 86% on room air
D. Respiratory rate of 24 breaths/minute
Correct Answer: C
Rationale: An oxygen saturation of 86% indicates significant hypoxemia and requires immediate
oxygen therapy and further evaluation.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy. What oxygen saturation should the nurse generally aim to maintain?
A. 100%
B. 98%–100%
C. 88%–92%
D. Above 95%
Correct Answer: C
Rationale: Maintaining oxygen saturation between 88% and 92% helps prevent suppression of
the respiratory drive while ensuring adequate oxygenation.
3. Which assessment finding is most consistent with left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Crackles in both lung bases
D. Enlarged liver
Correct Answer: C
Rationale: Left-sided heart failure commonly causes pulmonary congestion, resulting in crackles
and dyspnea.
, 4. A client reports crushing chest pain radiating to the left arm. What is the nurse's priority
action?
A. Obtain vital signs
B. Administer aspirin if prescribed and notify the provider
C. Encourage the client to rest
D. Obtain a urine specimen
Correct Answer: B
Rationale: Suspected myocardial infarction requires rapid intervention. Aspirin helps reduce
platelet aggregation and improves outcomes.
5. Which laboratory value is the most specific indicator of myocardial injury?
A. White blood cell count
B. Hemoglobin
C. Troponin I
D. Potassium
Correct Answer: C
Rationale: Troponin is the preferred cardiac biomarker because it is highly specific for
myocardial injury.
6. A client receiving furosemide should be monitored closely for which electrolyte
imbalance?
A. Hypernatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypermagnesemia
Correct Answer: C
Rationale: Loop diuretics increase potassium excretion, placing clients at risk for hypokalemia.
7. Which symptom is most commonly associated with hypoglycemia?
,A. Warm, dry skin
B. Polyuria
C. Diaphoresis and shakiness
D. Fruity breath odor
Correct Answer: C
Rationale: Hypoglycemia activates the sympathetic nervous system, causing sweating, tremors,
and tachycardia.
8. A client newly diagnosed with diabetes asks why foot care is important. What is the best
response?
A. Diabetes causes rapid nail growth.
B. Poor circulation and neuropathy increase injury risk.
C. Feet become stronger with diabetes.
D. Foot infections are uncommon.
Correct Answer: B
Rationale: Peripheral neuropathy and decreased circulation increase the likelihood of unnoticed
injuries and delayed healing.
9. Which assessment finding is expected in dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Tachycardia
D. Weight gain
Correct Answer: C
Rationale: Tachycardia develops as the body compensates for decreased circulating volume.
10. Which electrolyte imbalance commonly causes peaked T waves on an ECG?
A. Hypocalcemia
B. Hypokalemia
C. Hyperkalemia
D. Hypernatremia
, Correct Answer: C
Rationale: Peaked T waves are a classic ECG finding associated with hyperkalemia.
11. A client with chronic kidney disease has a potassium level of 6.4 mEq/L. Which
intervention is the priority?
A. Encourage fluids
B. Monitor intake and output only
C. Notify the provider immediately
D. Restrict protein intake
Correct Answer: C
Rationale: Severe hyperkalemia can cause life-threatening cardiac dysrhythmias and requires
immediate treatment.
12. Which client is at greatest risk for developing deep vein thrombosis (DVT)?
A. Client walking daily after surgery
B. Client on prolonged bed rest
C. Client drinking extra fluids
D. Client performing leg exercises
Correct Answer: B
Rationale: Immobility is a major risk factor for venous thromboembolism.
13. A client receiving heparin therapy develops bleeding gums. Which medication should the
nurse anticipate administering?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Atropine
Correct Answer: B
Rationale: Protamine sulfate reverses the anticoagulant effects of heparin.
GRADED
1. A nurse assesses a client admitted with community-acquired pneumonia. Which
assessment finding requires immediate intervention?
A. Temperature of 101.8°F (38.8°C)
B. Productive cough with yellow sputum
C. Oxygen saturation of 86% on room air
D. Respiratory rate of 24 breaths/minute
Correct Answer: C
Rationale: An oxygen saturation of 86% indicates significant hypoxemia and requires immediate
oxygen therapy and further evaluation.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy. What oxygen saturation should the nurse generally aim to maintain?
A. 100%
B. 98%–100%
C. 88%–92%
D. Above 95%
Correct Answer: C
Rationale: Maintaining oxygen saturation between 88% and 92% helps prevent suppression of
the respiratory drive while ensuring adequate oxygenation.
3. Which assessment finding is most consistent with left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Crackles in both lung bases
D. Enlarged liver
Correct Answer: C
Rationale: Left-sided heart failure commonly causes pulmonary congestion, resulting in crackles
and dyspnea.
, 4. A client reports crushing chest pain radiating to the left arm. What is the nurse's priority
action?
A. Obtain vital signs
B. Administer aspirin if prescribed and notify the provider
C. Encourage the client to rest
D. Obtain a urine specimen
Correct Answer: B
Rationale: Suspected myocardial infarction requires rapid intervention. Aspirin helps reduce
platelet aggregation and improves outcomes.
5. Which laboratory value is the most specific indicator of myocardial injury?
A. White blood cell count
B. Hemoglobin
C. Troponin I
D. Potassium
Correct Answer: C
Rationale: Troponin is the preferred cardiac biomarker because it is highly specific for
myocardial injury.
6. A client receiving furosemide should be monitored closely for which electrolyte
imbalance?
A. Hypernatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypermagnesemia
Correct Answer: C
Rationale: Loop diuretics increase potassium excretion, placing clients at risk for hypokalemia.
7. Which symptom is most commonly associated with hypoglycemia?
,A. Warm, dry skin
B. Polyuria
C. Diaphoresis and shakiness
D. Fruity breath odor
Correct Answer: C
Rationale: Hypoglycemia activates the sympathetic nervous system, causing sweating, tremors,
and tachycardia.
8. A client newly diagnosed with diabetes asks why foot care is important. What is the best
response?
A. Diabetes causes rapid nail growth.
B. Poor circulation and neuropathy increase injury risk.
C. Feet become stronger with diabetes.
D. Foot infections are uncommon.
Correct Answer: B
Rationale: Peripheral neuropathy and decreased circulation increase the likelihood of unnoticed
injuries and delayed healing.
9. Which assessment finding is expected in dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Tachycardia
D. Weight gain
Correct Answer: C
Rationale: Tachycardia develops as the body compensates for decreased circulating volume.
10. Which electrolyte imbalance commonly causes peaked T waves on an ECG?
A. Hypocalcemia
B. Hypokalemia
C. Hyperkalemia
D. Hypernatremia
, Correct Answer: C
Rationale: Peaked T waves are a classic ECG finding associated with hyperkalemia.
11. A client with chronic kidney disease has a potassium level of 6.4 mEq/L. Which
intervention is the priority?
A. Encourage fluids
B. Monitor intake and output only
C. Notify the provider immediately
D. Restrict protein intake
Correct Answer: C
Rationale: Severe hyperkalemia can cause life-threatening cardiac dysrhythmias and requires
immediate treatment.
12. Which client is at greatest risk for developing deep vein thrombosis (DVT)?
A. Client walking daily after surgery
B. Client on prolonged bed rest
C. Client drinking extra fluids
D. Client performing leg exercises
Correct Answer: B
Rationale: Immobility is a major risk factor for venous thromboembolism.
13. A client receiving heparin therapy develops bleeding gums. Which medication should the
nurse anticipate administering?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Atropine
Correct Answer: B
Rationale: Protamine sulfate reverses the anticoagulant effects of heparin.
