HONDROS NUR 212 Practice Exam
Questions and Answers with Rationales
Latest Versions
1. A nurse is assessing a patient who reports sudden shortness of breath and chest
pain. Which finding requires the nurse's priority attention?
A. Respiratory rate of 24/min
B. Oxygen saturation of 88%
C. Heart rate of 104/min
D. Mild anxiety
Answer: B. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates significant hypoxemia. Airway
and breathing are immediate priorities. The nurse should assess the patient's
respiratory status and initiate appropriate oxygen therapy according to the clinical
situation and orders/protocol.
2. Which assessment finding is most consistent with fluid volume deficit?
A. Bounding peripheral pulses
B. Crackles in both lung bases
C. Orthostatic hypotension
D. Jugular venous distention
Answer: C. Orthostatic hypotension
Rationale: Fluid volume deficit decreases circulating blood volume and can cause
orthostatic hypotension, tachycardia, dry mucous membranes, and decreased urine
output. Bounding pulses, crackles, and JVD are more consistent with fluid excess.
3. A patient receiving IV potassium chloride reports burning at the IV site. What
should the nurse do first?
,A. Increase the infusion rate
B. Stop the infusion and assess the IV site
C. Apply a warm compress and continue the infusion
D. Flush the IV rapidly
Answer: B. Stop the infusion and assess the IV site
Rationale: Potassium chloride is irritating to veins and can cause serious tissue
injury if infiltration or extravasation occurs. The nurse should stop the infusion and
assess the IV site before taking further action.
4. Which finding should the nurse expect in a patient experiencing hypoglycemia?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and tremors
D. Increased thirst only
Answer: C. Diaphoresis and tremors
Rationale: Hypoglycemia commonly causes adrenergic symptoms such as
sweating, tremors, palpitations, anxiety, and hunger. Neurologic manifestations
may include confusion, weakness, and seizures.
5. A nurse is teaching a patient about incentive spirometry after surgery. Which
instruction is correct?
A. "Blow forcefully into the device."
B. "Use the device only when you feel short of breath."
C. "Inhale slowly and deeply through the mouthpiece."
D. "Use the device once every 8 hours."
Answer: C. "Inhale slowly and deeply through the mouthpiece."
Rationale: Incentive spirometry promotes lung expansion and helps prevent
postoperative atelectasis. The patient should sit upright, seal the lips around the
mouthpiece, and inhale slowly and deeply.
,6. Which patient should the nurse assess first?
A. A patient with chronic arthritis reporting pain of 6/10
B. A postoperative patient with new-onset confusion
C. A patient requesting assistance with bathing
D. A patient awaiting discharge instructions
Answer: B. A postoperative patient with new-onset confusion
Rationale: New-onset confusion may indicate hypoxia, infection, medication
effects, metabolic abnormalities, or another acute complication. An acute change in
mental status warrants prompt assessment.
7. A patient has a potassium level of 6.2 mEq/L. Which assessment finding is most
concerning?
A. Muscle weakness
B. Nausea
C. Cardiac dysrhythmia
D. Fatigue
Answer: C. Cardiac dysrhythmia
Rationale: Hyperkalemia can cause dangerous cardiac conduction abnormalities
and dysrhythmias. Continuous cardiac monitoring and prompt treatment may be
necessary depending on the patient's condition.
8. Which nursing intervention is most appropriate for preventing pressure injuries
in an immobile patient?
A. Massage reddened bony prominences
B. Reposition the patient regularly
C. Keep the patient's skin moist
D. Restrict protein intake
, Answer: B. Reposition the patient regularly
Rationale: Regular repositioning reduces prolonged pressure over bony
prominences. The nurse should also maintain skin hygiene, manage moisture,
optimize nutrition, and use pressure-redistributing surfaces when appropriate.
Massaging reddened areas can cause additional tissue damage.
9. A patient taking an opioid analgesic becomes difficult to arouse and has a
respiratory rate of 7/min. What is the priority nursing action?
A. Allow the patient to sleep
B. Administer another dose of the opioid
C. Assess airway and breathing and initiate emergency interventions
D. Give the patient oral fluids
Answer: C. Assess airway and breathing and initiate emergency interventions
Rationale: Severe respiratory depression is a potentially life-threatening opioid
adverse effect. Airway and breathing take priority. The nurse should provide
appropriate emergency support and anticipate administration of an opioid
antagonist such as naloxone when indicated.
10. Which finding indicates that a patient's infection may be worsening?
A. Temperature decreases from 38.5°C to 37.5°C
B. White blood cell count returns toward normal
C. Increasing heart rate with hypotension
D. Improved appetite
Answer: C. Increasing heart rate with hypotension
Rationale: Tachycardia and hypotension can indicate systemic deterioration and
possible sepsis or septic shock, particularly when associated with an infection.
Prompt assessment and intervention are required.
Questions and Answers with Rationales
Latest Versions
1. A nurse is assessing a patient who reports sudden shortness of breath and chest
pain. Which finding requires the nurse's priority attention?
A. Respiratory rate of 24/min
B. Oxygen saturation of 88%
C. Heart rate of 104/min
D. Mild anxiety
Answer: B. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates significant hypoxemia. Airway
and breathing are immediate priorities. The nurse should assess the patient's
respiratory status and initiate appropriate oxygen therapy according to the clinical
situation and orders/protocol.
2. Which assessment finding is most consistent with fluid volume deficit?
A. Bounding peripheral pulses
B. Crackles in both lung bases
C. Orthostatic hypotension
D. Jugular venous distention
Answer: C. Orthostatic hypotension
Rationale: Fluid volume deficit decreases circulating blood volume and can cause
orthostatic hypotension, tachycardia, dry mucous membranes, and decreased urine
output. Bounding pulses, crackles, and JVD are more consistent with fluid excess.
3. A patient receiving IV potassium chloride reports burning at the IV site. What
should the nurse do first?
,A. Increase the infusion rate
B. Stop the infusion and assess the IV site
C. Apply a warm compress and continue the infusion
D. Flush the IV rapidly
Answer: B. Stop the infusion and assess the IV site
Rationale: Potassium chloride is irritating to veins and can cause serious tissue
injury if infiltration or extravasation occurs. The nurse should stop the infusion and
assess the IV site before taking further action.
4. Which finding should the nurse expect in a patient experiencing hypoglycemia?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and tremors
D. Increased thirst only
Answer: C. Diaphoresis and tremors
Rationale: Hypoglycemia commonly causes adrenergic symptoms such as
sweating, tremors, palpitations, anxiety, and hunger. Neurologic manifestations
may include confusion, weakness, and seizures.
5. A nurse is teaching a patient about incentive spirometry after surgery. Which
instruction is correct?
A. "Blow forcefully into the device."
B. "Use the device only when you feel short of breath."
C. "Inhale slowly and deeply through the mouthpiece."
D. "Use the device once every 8 hours."
Answer: C. "Inhale slowly and deeply through the mouthpiece."
Rationale: Incentive spirometry promotes lung expansion and helps prevent
postoperative atelectasis. The patient should sit upright, seal the lips around the
mouthpiece, and inhale slowly and deeply.
,6. Which patient should the nurse assess first?
A. A patient with chronic arthritis reporting pain of 6/10
B. A postoperative patient with new-onset confusion
C. A patient requesting assistance with bathing
D. A patient awaiting discharge instructions
Answer: B. A postoperative patient with new-onset confusion
Rationale: New-onset confusion may indicate hypoxia, infection, medication
effects, metabolic abnormalities, or another acute complication. An acute change in
mental status warrants prompt assessment.
7. A patient has a potassium level of 6.2 mEq/L. Which assessment finding is most
concerning?
A. Muscle weakness
B. Nausea
C. Cardiac dysrhythmia
D. Fatigue
Answer: C. Cardiac dysrhythmia
Rationale: Hyperkalemia can cause dangerous cardiac conduction abnormalities
and dysrhythmias. Continuous cardiac monitoring and prompt treatment may be
necessary depending on the patient's condition.
8. Which nursing intervention is most appropriate for preventing pressure injuries
in an immobile patient?
A. Massage reddened bony prominences
B. Reposition the patient regularly
C. Keep the patient's skin moist
D. Restrict protein intake
, Answer: B. Reposition the patient regularly
Rationale: Regular repositioning reduces prolonged pressure over bony
prominences. The nurse should also maintain skin hygiene, manage moisture,
optimize nutrition, and use pressure-redistributing surfaces when appropriate.
Massaging reddened areas can cause additional tissue damage.
9. A patient taking an opioid analgesic becomes difficult to arouse and has a
respiratory rate of 7/min. What is the priority nursing action?
A. Allow the patient to sleep
B. Administer another dose of the opioid
C. Assess airway and breathing and initiate emergency interventions
D. Give the patient oral fluids
Answer: C. Assess airway and breathing and initiate emergency interventions
Rationale: Severe respiratory depression is a potentially life-threatening opioid
adverse effect. Airway and breathing take priority. The nurse should provide
appropriate emergency support and anticipate administration of an opioid
antagonist such as naloxone when indicated.
10. Which finding indicates that a patient's infection may be worsening?
A. Temperature decreases from 38.5°C to 37.5°C
B. White blood cell count returns toward normal
C. Increasing heart rate with hypotension
D. Improved appetite
Answer: C. Increasing heart rate with hypotension
Rationale: Tachycardia and hypotension can indicate systemic deterioration and
possible sepsis or septic shock, particularly when associated with an infection.
Prompt assessment and intervention are required.
