NUR 201 — Exam 2 questions verified with correct answers
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Question 1
A nurse is caring for a client who reports sudden shortness of breath. Which action should the
nurse take first?
A. Obtain the client's dietary history
B. Assess airway, breathing, oxygen saturation, and vital signs
C. Ask about the client's sleep pattern
D. Provide discharge instructions
Answer: B. Assess airway, breathing, oxygen saturation, and vital signs
Rationale: Acute respiratory difficulty can represent a life-threatening condition. The nurse
should immediately assess airway and breathing and determine the severity of the problem.
Question 2
Which finding indicates possible hypoxemia?
A. Oxygen saturation of 97%
B. Pink skin and normal breathing
C. Cyanosis and restlessness
D. Respiratory rate of 16/min
Answer: C. Cyanosis and restlessness
Rationale: Cyanosis, restlessness, confusion, and changes in respiratory effort can indicate
inadequate oxygenation and require prompt assessment.
Question 3
A client with dyspnea is most appropriately positioned in:
A. High-Fowler's position
B. Flat supine position
C. Trendelenburg position
D. Prone position
,Answer: A. High-Fowler's position
Rationale: Elevating the head of the bed promotes lung expansion and can decrease the work of
breathing.
Question 4
A nurse is assessing a client with chest pain. Which finding is most concerning?
A. Pain that occurs briefly after changing position
B. Crushing chest pressure with diaphoresis and nausea
C. Mild pain after exercise that resolves immediately
D. Occasional discomfort lasting a few seconds
Answer: B. Crushing chest pressure with diaphoresis and nausea
Rationale: Crushing or pressure-like chest pain accompanied by diaphoresis and nausea can
indicate acute coronary syndrome and requires immediate evaluation.
Question 5
Which assessment finding should the nurse recognize as potentially indicating heart failure?
A. Bilateral dependent edema and shortness of breath
B. Increased appetite
C. Clear lungs with normal exercise tolerance
D. Warm, dry skin only
Answer: A. Bilateral dependent edema and shortness of breath
Rationale: Heart failure may cause fluid retention, peripheral edema, pulmonary congestion,
dyspnea, fatigue, and weight gain.
Question 6
A client with heart failure reports a rapid increase in weight over several days. What does this
most likely indicate?
A. Loss of muscle mass
B. Fluid retention
,C. Improved nutritional status
D. Dehydration
Answer: B. Fluid retention
Rationale: Rapid weight gain over a short period commonly reflects fluid accumulation rather
than true tissue gain.
Question 7
Which intervention is appropriate for a client with heart failure?
A. Monitor daily weight and fluid status.
B. Encourage unlimited sodium intake.
C. Avoid monitoring respiratory status.
D. Encourage excessive fluid intake for all clients.
Answer: A. Monitor daily weight and fluid status.
Rationale: Daily weights and monitoring of intake/output and respiratory status help identify
fluid accumulation and worsening heart failure.
Question 8
A client has a blood pressure of 86/52 mm Hg and reports dizziness. What is the nurse's priority?
A. Assist the client to a safe position and assess the client's condition.
B. Encourage the client to walk.
C. Give an antihypertensive medication.
D. Leave the client unattended.
Answer: A.
Rationale: Hypotension with dizziness increases the risk of falls and may indicate inadequate
perfusion. Immediate safety and assessment are priorities.
Question 9
Which finding is commonly associated with dehydration?
, A. Bounding pulse
B. Dry mucous membranes
C. Generalized edema
D. Crackles in the lungs
Answer: B. Dry mucous membranes
Rationale: Dehydration may cause dry mucous membranes, thirst, concentrated urine, decreased
urine output, tachycardia, and weakness.
Question 10
Which client is at greatest risk for fluid volume excess?
A. Client with severe vomiting
B. Client with heart failure and impaired renal function
C. Client with increased sweating after exercise
D. Client with mild diarrhea
Answer: B. Client with heart failure and impaired renal function
Rationale: Heart failure and renal impairment can decrease the body's ability to remove excess
fluid, increasing the risk of fluid volume overload.
Question 11
A client with diabetes is sweating, trembling, and confused. Which condition should the nurse
suspect?
A. Hyperglycemia
B. Hypoglycemia
C. Hypernatremia
D. Hypertension
Answer: B. Hypoglycemia
Rationale: Sweating, tremors, hunger, tachycardia, irritability, and confusion are common
manifestations of low blood glucose.
Question 12
plus rationales 2026/2027 instant pdf
Question 1
A nurse is caring for a client who reports sudden shortness of breath. Which action should the
nurse take first?
A. Obtain the client's dietary history
B. Assess airway, breathing, oxygen saturation, and vital signs
C. Ask about the client's sleep pattern
D. Provide discharge instructions
Answer: B. Assess airway, breathing, oxygen saturation, and vital signs
Rationale: Acute respiratory difficulty can represent a life-threatening condition. The nurse
should immediately assess airway and breathing and determine the severity of the problem.
Question 2
Which finding indicates possible hypoxemia?
A. Oxygen saturation of 97%
B. Pink skin and normal breathing
C. Cyanosis and restlessness
D. Respiratory rate of 16/min
Answer: C. Cyanosis and restlessness
Rationale: Cyanosis, restlessness, confusion, and changes in respiratory effort can indicate
inadequate oxygenation and require prompt assessment.
Question 3
A client with dyspnea is most appropriately positioned in:
A. High-Fowler's position
B. Flat supine position
C. Trendelenburg position
D. Prone position
,Answer: A. High-Fowler's position
Rationale: Elevating the head of the bed promotes lung expansion and can decrease the work of
breathing.
Question 4
A nurse is assessing a client with chest pain. Which finding is most concerning?
A. Pain that occurs briefly after changing position
B. Crushing chest pressure with diaphoresis and nausea
C. Mild pain after exercise that resolves immediately
D. Occasional discomfort lasting a few seconds
Answer: B. Crushing chest pressure with diaphoresis and nausea
Rationale: Crushing or pressure-like chest pain accompanied by diaphoresis and nausea can
indicate acute coronary syndrome and requires immediate evaluation.
Question 5
Which assessment finding should the nurse recognize as potentially indicating heart failure?
A. Bilateral dependent edema and shortness of breath
B. Increased appetite
C. Clear lungs with normal exercise tolerance
D. Warm, dry skin only
Answer: A. Bilateral dependent edema and shortness of breath
Rationale: Heart failure may cause fluid retention, peripheral edema, pulmonary congestion,
dyspnea, fatigue, and weight gain.
Question 6
A client with heart failure reports a rapid increase in weight over several days. What does this
most likely indicate?
A. Loss of muscle mass
B. Fluid retention
,C. Improved nutritional status
D. Dehydration
Answer: B. Fluid retention
Rationale: Rapid weight gain over a short period commonly reflects fluid accumulation rather
than true tissue gain.
Question 7
Which intervention is appropriate for a client with heart failure?
A. Monitor daily weight and fluid status.
B. Encourage unlimited sodium intake.
C. Avoid monitoring respiratory status.
D. Encourage excessive fluid intake for all clients.
Answer: A. Monitor daily weight and fluid status.
Rationale: Daily weights and monitoring of intake/output and respiratory status help identify
fluid accumulation and worsening heart failure.
Question 8
A client has a blood pressure of 86/52 mm Hg and reports dizziness. What is the nurse's priority?
A. Assist the client to a safe position and assess the client's condition.
B. Encourage the client to walk.
C. Give an antihypertensive medication.
D. Leave the client unattended.
Answer: A.
Rationale: Hypotension with dizziness increases the risk of falls and may indicate inadequate
perfusion. Immediate safety and assessment are priorities.
Question 9
Which finding is commonly associated with dehydration?
, A. Bounding pulse
B. Dry mucous membranes
C. Generalized edema
D. Crackles in the lungs
Answer: B. Dry mucous membranes
Rationale: Dehydration may cause dry mucous membranes, thirst, concentrated urine, decreased
urine output, tachycardia, and weakness.
Question 10
Which client is at greatest risk for fluid volume excess?
A. Client with severe vomiting
B. Client with heart failure and impaired renal function
C. Client with increased sweating after exercise
D. Client with mild diarrhea
Answer: B. Client with heart failure and impaired renal function
Rationale: Heart failure and renal impairment can decrease the body's ability to remove excess
fluid, increasing the risk of fluid volume overload.
Question 11
A client with diabetes is sweating, trembling, and confused. Which condition should the nurse
suspect?
A. Hyperglycemia
B. Hypoglycemia
C. Hypernatremia
D. Hypertension
Answer: B. Hypoglycemia
Rationale: Sweating, tremors, hunger, tachycardia, irritability, and confusion are common
manifestations of low blood glucose.
Question 12
