NUR 215 Exam 4 Questions With Correct
Answers (Verified Answers) Plus Rationales
2026 Q&A | Instant Download Pdf
1. A nurse is caring for a client admitted with acute decompensated
heart failure. Which assessment finding requires immediate
intervention?
A. Bilateral ankle edema
B. Weight gain of 1 lb overnight
C. Oxygen saturation of 84% on room air
D. Mild fatigue after ambulation
Rationale: Oxygen saturation of 84% indicates severe hypoxemia and
impaired gas exchange, making it the highest priority according to the
ABCs (Airway, Breathing, Circulation). Peripheral edema, minor
weight gain, and fatigue are expected findings in heart failure but are
not immediately life-threatening.
2. A client with type 1 diabetes becomes diaphoretic and confused.
What is the nurse's priority action?
,A. Administer long-acting insulin
B. Encourage exercise
C. Check the client's blood glucose level
D. Restrict oral fluids
Rationale: Diaphoresis and confusion suggest hypoglycemia. The
nurse should first verify the blood glucose level to confirm the
diagnosis before administering treatment. Prompt assessment
prevents worsening neurological impairment.
3. Which laboratory value should the nurse report immediately?
A. Hemoglobin 13.8 g/dL
B. Sodium 138 mEq/L
C. Potassium 6.4 mEq/L
D. Platelets 220,000/mm³
Rationale: A potassium level of 6.4 mEq/L represents severe
hyperkalemia and significantly increases the risk of life-threatening
cardiac dysrhythmias. Immediate intervention is required.
4. A client with chronic obstructive pulmonary disease (COPD)
should receive oxygen therapy at what goal oxygen saturation?
A. 100%
B. 98%–100%
,C. 88%–92%
D. Above 95%
Rationale: Clients with COPD often have chronic carbon dioxide
retention. Maintaining oxygen saturation between 88% and 92%
provides adequate oxygenation while minimizing the risk of
suppressing respiratory drive.
5. Which finding indicates improvement in a client receiving
treatment for pneumonia?
A. Respiratory rate increases to 30 breaths/min
B. Crackles decrease and oxygen saturation improves
C. White blood cell count continues rising
D. Fever increases to 103°F (39.4°C)
Rationale: Improved oxygenation and decreased adventitious lung
sounds indicate resolution of pulmonary inflammation and better gas
exchange.
6. A postoperative client reports calf pain. Which nursing action is
the priority?
A. Massage the affected leg
B. Encourage ambulation immediately
, C. Apply a heating pad
D. Assess for redness, swelling, and notify the provider
Rationale: Calf pain may indicate deep vein thrombosis. Massaging
the extremity may dislodge a clot. Prompt assessment and provider
notification help prevent pulmonary embolism.
7. Which client is at highest risk for developing pressure injuries?
A. Ambulatory client with hypertension
B. Immobile older adult with poor nutrition
C. Young client with asthma
D. Postpartum client
Rationale: Immobility combined with malnutrition significantly
increases tissue ischemia and decreases the body's ability to heal,
making pressure injury development more likely.
8. A nurse is educating a client taking warfarin. Which statement
indicates understanding?
A. "I'll stop taking the medication if I bruise."
B. "I'll maintain a consistent intake of foods containing vitamin K."
C. "I'll double my dose if I miss one."
D. "I'll take aspirin for headaches."
Answers (Verified Answers) Plus Rationales
2026 Q&A | Instant Download Pdf
1. A nurse is caring for a client admitted with acute decompensated
heart failure. Which assessment finding requires immediate
intervention?
A. Bilateral ankle edema
B. Weight gain of 1 lb overnight
C. Oxygen saturation of 84% on room air
D. Mild fatigue after ambulation
Rationale: Oxygen saturation of 84% indicates severe hypoxemia and
impaired gas exchange, making it the highest priority according to the
ABCs (Airway, Breathing, Circulation). Peripheral edema, minor
weight gain, and fatigue are expected findings in heart failure but are
not immediately life-threatening.
2. A client with type 1 diabetes becomes diaphoretic and confused.
What is the nurse's priority action?
,A. Administer long-acting insulin
B. Encourage exercise
C. Check the client's blood glucose level
D. Restrict oral fluids
Rationale: Diaphoresis and confusion suggest hypoglycemia. The
nurse should first verify the blood glucose level to confirm the
diagnosis before administering treatment. Prompt assessment
prevents worsening neurological impairment.
3. Which laboratory value should the nurse report immediately?
A. Hemoglobin 13.8 g/dL
B. Sodium 138 mEq/L
C. Potassium 6.4 mEq/L
D. Platelets 220,000/mm³
Rationale: A potassium level of 6.4 mEq/L represents severe
hyperkalemia and significantly increases the risk of life-threatening
cardiac dysrhythmias. Immediate intervention is required.
4. A client with chronic obstructive pulmonary disease (COPD)
should receive oxygen therapy at what goal oxygen saturation?
A. 100%
B. 98%–100%
,C. 88%–92%
D. Above 95%
Rationale: Clients with COPD often have chronic carbon dioxide
retention. Maintaining oxygen saturation between 88% and 92%
provides adequate oxygenation while minimizing the risk of
suppressing respiratory drive.
5. Which finding indicates improvement in a client receiving
treatment for pneumonia?
A. Respiratory rate increases to 30 breaths/min
B. Crackles decrease and oxygen saturation improves
C. White blood cell count continues rising
D. Fever increases to 103°F (39.4°C)
Rationale: Improved oxygenation and decreased adventitious lung
sounds indicate resolution of pulmonary inflammation and better gas
exchange.
6. A postoperative client reports calf pain. Which nursing action is
the priority?
A. Massage the affected leg
B. Encourage ambulation immediately
, C. Apply a heating pad
D. Assess for redness, swelling, and notify the provider
Rationale: Calf pain may indicate deep vein thrombosis. Massaging
the extremity may dislodge a clot. Prompt assessment and provider
notification help prevent pulmonary embolism.
7. Which client is at highest risk for developing pressure injuries?
A. Ambulatory client with hypertension
B. Immobile older adult with poor nutrition
C. Young client with asthma
D. Postpartum client
Rationale: Immobility combined with malnutrition significantly
increases tissue ischemia and decreases the body's ability to heal,
making pressure injury development more likely.
8. A nurse is educating a client taking warfarin. Which statement
indicates understanding?
A. "I'll stop taking the medication if I bruise."
B. "I'll maintain a consistent intake of foods containing vitamin K."
C. "I'll double my dose if I miss one."
D. "I'll take aspirin for headaches."
