NSG 434 Nursing Care Exam Practice Questions (2026 Edition)
Questions and Answers with Detailed Rationales
Question 1
A nurse is caring for a patient admitted with acute heart failure. Which
assessment finding requires immediate intervention?
A. Blood pressure of 132/78 mm Hg
B. Bilateral crackles and oxygen saturation of 86% on room air
C. Heart rate of 88 beats/minute
D. Mild ankle edema at the end of the day
Correct Answer: B. Bilateral Crackles and Oxygen Saturation of 86% on
Room Air
Rationale:
An oxygen saturation below 90% with crackles indicates impaired gas
exchange and pulmonary edema. Airway, breathing, and oxygenation
are the immediate priorities.
Question 2
A nurse is assessing a postoperative patient. Which finding is the
highest priority?
A. Pain rated 6/10
B. Urine output of 15 mL/hour
C. Temperature of 99.2°F (37.3°C)
D. Mild nausea
Correct Answer: B. Urine Output of 15 mL/Hour
,Rationale:
Urine output less than 30 mL/hour may indicate inadequate renal
perfusion, hypovolemia, or shock and requires prompt assessment.
Question 3
A patient with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which nursing intervention is most
appropriate?
A. Administer high-flow oxygen without monitoring.
B. Monitor oxygen saturation and administer oxygen as prescribed.
C. Discontinue oxygen once breathing improves.
D. Encourage the patient to hold their breath.
Correct Answer: B. Monitor Oxygen Saturation and Administer Oxygen
as Prescribed
Rationale:
Patients with COPD require careful oxygen administration and
continuous monitoring to maintain appropriate oxygenation.
Question 4
A nurse is caring for a patient with diabetes mellitus. Which assessment
finding suggests hypoglycemia?
A. Warm, dry skin
B. Confusion, diaphoresis, and tremors
C. Polyuria and excessive thirst
D. Fruity breath odor
,Correct Answer: B. Confusion, Diaphoresis, and Tremors
Rationale:
Hypoglycemia commonly presents with sweating, shakiness, confusion,
tachycardia, and hunger.
Question 5
Which laboratory value requires immediate reporting?
A. Sodium 139 mEq/L
B. Potassium 6.2 mEq/L
C. Calcium 9.1 mg/dL
D. Hemoglobin 13.8 g/dL
Correct Answer: B. Potassium 6.2 mEq/L
Rationale:
Severe hyperkalemia can cause life-threatening cardiac dysrhythmias
and requires immediate intervention.
Question 6
A patient receiving intravenous antibiotics develops hives, wheezing,
and hypotension. What is the nurse's first action?
A. Slow the infusion
B. Stop the medication immediately
C. Continue the medication
D. Document the reaction
Correct Answer: B. Stop the Medication Immediately
, Rationale:
These findings indicate possible anaphylaxis. The medication should be
stopped immediately while emergency treatment is initiated.
Question 7
Which patient should the nurse assess first?
A. Patient with chronic arthritis reporting pain 5/10
B. Patient with chest pain and diaphoresis
C. Patient requesting assistance with bathing
D. Patient awaiting discharge instructions
Correct Answer: B. Patient With Chest Pain and Diaphoresis
Rationale:
Chest pain with diaphoresis may indicate acute coronary syndrome and
requires immediate evaluation.
Question 8
Which intervention best prevents hospital-acquired infections?
A. Routine antibiotic use
B. Proper hand hygiene before and after patient contact
C. Wearing gloves only
D. Daily chest X-rays
Correct Answer: B. Proper Hand Hygiene Before and After Patient
Contact
Questions and Answers with Detailed Rationales
Question 1
A nurse is caring for a patient admitted with acute heart failure. Which
assessment finding requires immediate intervention?
A. Blood pressure of 132/78 mm Hg
B. Bilateral crackles and oxygen saturation of 86% on room air
C. Heart rate of 88 beats/minute
D. Mild ankle edema at the end of the day
Correct Answer: B. Bilateral Crackles and Oxygen Saturation of 86% on
Room Air
Rationale:
An oxygen saturation below 90% with crackles indicates impaired gas
exchange and pulmonary edema. Airway, breathing, and oxygenation
are the immediate priorities.
Question 2
A nurse is assessing a postoperative patient. Which finding is the
highest priority?
A. Pain rated 6/10
B. Urine output of 15 mL/hour
C. Temperature of 99.2°F (37.3°C)
D. Mild nausea
Correct Answer: B. Urine Output of 15 mL/Hour
,Rationale:
Urine output less than 30 mL/hour may indicate inadequate renal
perfusion, hypovolemia, or shock and requires prompt assessment.
Question 3
A patient with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which nursing intervention is most
appropriate?
A. Administer high-flow oxygen without monitoring.
B. Monitor oxygen saturation and administer oxygen as prescribed.
C. Discontinue oxygen once breathing improves.
D. Encourage the patient to hold their breath.
Correct Answer: B. Monitor Oxygen Saturation and Administer Oxygen
as Prescribed
Rationale:
Patients with COPD require careful oxygen administration and
continuous monitoring to maintain appropriate oxygenation.
Question 4
A nurse is caring for a patient with diabetes mellitus. Which assessment
finding suggests hypoglycemia?
A. Warm, dry skin
B. Confusion, diaphoresis, and tremors
C. Polyuria and excessive thirst
D. Fruity breath odor
,Correct Answer: B. Confusion, Diaphoresis, and Tremors
Rationale:
Hypoglycemia commonly presents with sweating, shakiness, confusion,
tachycardia, and hunger.
Question 5
Which laboratory value requires immediate reporting?
A. Sodium 139 mEq/L
B. Potassium 6.2 mEq/L
C. Calcium 9.1 mg/dL
D. Hemoglobin 13.8 g/dL
Correct Answer: B. Potassium 6.2 mEq/L
Rationale:
Severe hyperkalemia can cause life-threatening cardiac dysrhythmias
and requires immediate intervention.
Question 6
A patient receiving intravenous antibiotics develops hives, wheezing,
and hypotension. What is the nurse's first action?
A. Slow the infusion
B. Stop the medication immediately
C. Continue the medication
D. Document the reaction
Correct Answer: B. Stop the Medication Immediately
, Rationale:
These findings indicate possible anaphylaxis. The medication should be
stopped immediately while emergency treatment is initiated.
Question 7
Which patient should the nurse assess first?
A. Patient with chronic arthritis reporting pain 5/10
B. Patient with chest pain and diaphoresis
C. Patient requesting assistance with bathing
D. Patient awaiting discharge instructions
Correct Answer: B. Patient With Chest Pain and Diaphoresis
Rationale:
Chest pain with diaphoresis may indicate acute coronary syndrome and
requires immediate evaluation.
Question 8
Which intervention best prevents hospital-acquired infections?
A. Routine antibiotic use
B. Proper hand hygiene before and after patient contact
C. Wearing gloves only
D. Daily chest X-rays
Correct Answer: B. Proper Hand Hygiene Before and After Patient
Contact
