NUR 257 Clinical Judgment Exam Questions
with Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download PDF
Question 1
A nurse assesses a client who is 8 hours postoperative following
abdominal surgery. The client reports increasing abdominal pain
despite receiving prescribed analgesia. Which finding requires
the nurse's priority attention?
A. Pain rated 7/10
B. Temperature of 37.6°C (99.7°F)
C. Heart rate of 118/min with blood pressure of 88/54 mm Hg
D. Reduced appetite
Correct answer: C. Heart rate of 118/min with blood pressure
of 88/54 mm Hg
The combination of tachycardia and hypotension suggests
possible hypovolemia, hemorrhage, or another form of
circulatory compromise. These findings indicate an immediate
threat to perfusion and therefore take priority over pain, mild
temperature elevation, or appetite changes. The nurse should
rapidly reassess the client, inspect for bleeding, assess the
surgical site and drains, and notify the appropriate provider
,while initiating emergency interventions according to the
client's condition and institutional protocol.
Question 2
A client with heart failure suddenly develops severe dyspnea,
bilateral crackles, and pink, frothy sputum. Which action should
the nurse take first?
A. Encourage oral fluids
B. Place the client in a high-Fowler position
C. Obtain the client's daily weight
D. Assist the client to the bathroom
Correct answer: B. Place the client in a high-Fowler position
The findings are consistent with acute pulmonary edema, which
can rapidly impair oxygenation. Placing the client upright
improves lung expansion and can reduce venous return to the
heart, helping decrease pulmonary congestion. The nurse
should immediately assess oxygen saturation and respiratory
status and provide oxygen or other prescribed emergency
interventions. Fluid intake, weight, and ambulation are not the
immediate priorities during acute respiratory compromise.
Question 3
,A nurse is caring for a client with diabetes mellitus who is
awake, diaphoretic, shaky, and confused. The blood glucose
level is 54 mg/dL (3.0 mmol/L). What is the nurse's priority
action?
A. Administer the client's scheduled insulin
B. Give 15 g of rapid-acting carbohydrate
C. Restrict oral intake
D. Administer a high-protein meal immediately
Correct answer: B. Give 15 g of rapid-acting carbohydrate
The client's symptoms and glucose level indicate hypoglycemia.
Because the client is awake and able to swallow, rapid-acting
carbohydrate is the appropriate immediate treatment. Blood
glucose should generally be rechecked after approximately 15
minutes, with additional treatment provided if hypoglycemia
persists. Insulin would worsen the condition, while restricting
oral intake is inappropriate in an alert client who can safely
swallow.
Question 4
A client receiving an opioid analgesic becomes difficult to
arouse. Respirations are 7/min, and oxygen saturation is 86%.
Which action is most appropriate?
, A. Allow the client to sleep
B. Administer another opioid dose
C. Stimulate the client and initiate immediate respiratory
support measures
D. Offer oral fluids
Correct answer: C. Stimulate the client and initiate immediate
respiratory support measures
Marked respiratory depression after opioid administration is an
emergency. The nurse should attempt to arouse the client,
assess airway and breathing, provide oxygen and ventilatory
support as indicated, and prepare to administer naloxone
according to the prescription or emergency protocol. The
priority is restoration of adequate ventilation and oxygenation,
not pain management or oral intake.
Question 5
A client with pneumonia has a respiratory rate of 30/min,
oxygen saturation of 88%, and increasing confusion. Which
finding is most concerning?
A. Productive cough
B. Temperature of 38.2°C (100.8°F)
C. Oxygen saturation of 88% with altered mental status
D. Fatigue
with Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download PDF
Question 1
A nurse assesses a client who is 8 hours postoperative following
abdominal surgery. The client reports increasing abdominal pain
despite receiving prescribed analgesia. Which finding requires
the nurse's priority attention?
A. Pain rated 7/10
B. Temperature of 37.6°C (99.7°F)
C. Heart rate of 118/min with blood pressure of 88/54 mm Hg
D. Reduced appetite
Correct answer: C. Heart rate of 118/min with blood pressure
of 88/54 mm Hg
The combination of tachycardia and hypotension suggests
possible hypovolemia, hemorrhage, or another form of
circulatory compromise. These findings indicate an immediate
threat to perfusion and therefore take priority over pain, mild
temperature elevation, or appetite changes. The nurse should
rapidly reassess the client, inspect for bleeding, assess the
surgical site and drains, and notify the appropriate provider
,while initiating emergency interventions according to the
client's condition and institutional protocol.
Question 2
A client with heart failure suddenly develops severe dyspnea,
bilateral crackles, and pink, frothy sputum. Which action should
the nurse take first?
A. Encourage oral fluids
B. Place the client in a high-Fowler position
C. Obtain the client's daily weight
D. Assist the client to the bathroom
Correct answer: B. Place the client in a high-Fowler position
The findings are consistent with acute pulmonary edema, which
can rapidly impair oxygenation. Placing the client upright
improves lung expansion and can reduce venous return to the
heart, helping decrease pulmonary congestion. The nurse
should immediately assess oxygen saturation and respiratory
status and provide oxygen or other prescribed emergency
interventions. Fluid intake, weight, and ambulation are not the
immediate priorities during acute respiratory compromise.
Question 3
,A nurse is caring for a client with diabetes mellitus who is
awake, diaphoretic, shaky, and confused. The blood glucose
level is 54 mg/dL (3.0 mmol/L). What is the nurse's priority
action?
A. Administer the client's scheduled insulin
B. Give 15 g of rapid-acting carbohydrate
C. Restrict oral intake
D. Administer a high-protein meal immediately
Correct answer: B. Give 15 g of rapid-acting carbohydrate
The client's symptoms and glucose level indicate hypoglycemia.
Because the client is awake and able to swallow, rapid-acting
carbohydrate is the appropriate immediate treatment. Blood
glucose should generally be rechecked after approximately 15
minutes, with additional treatment provided if hypoglycemia
persists. Insulin would worsen the condition, while restricting
oral intake is inappropriate in an alert client who can safely
swallow.
Question 4
A client receiving an opioid analgesic becomes difficult to
arouse. Respirations are 7/min, and oxygen saturation is 86%.
Which action is most appropriate?
, A. Allow the client to sleep
B. Administer another opioid dose
C. Stimulate the client and initiate immediate respiratory
support measures
D. Offer oral fluids
Correct answer: C. Stimulate the client and initiate immediate
respiratory support measures
Marked respiratory depression after opioid administration is an
emergency. The nurse should attempt to arouse the client,
assess airway and breathing, provide oxygen and ventilatory
support as indicated, and prepare to administer naloxone
according to the prescription or emergency protocol. The
priority is restoration of adequate ventilation and oxygenation,
not pain management or oral intake.
Question 5
A client with pneumonia has a respiratory rate of 30/min,
oxygen saturation of 88%, and increasing confusion. Which
finding is most concerning?
A. Productive cough
B. Temperature of 38.2°C (100.8°F)
C. Oxygen saturation of 88% with altered mental status
D. Fatigue
