NUR 257 Comprehensive Final Exam — Exam
Questions with Correct Answers
(VerifiedAnswers) Plus Rationales 2026 Q&A
Instant Download PDF
1. A nurse is assessing a client who has developed acute
shortness of breath. Which assessment finding requires the
nurse's immediate intervention?
A. Respiratory rate of 22/min
B. Oxygen saturation of 94%
C. New onset of confusion and restlessness
D. Mild anxiety related to dyspnea
Correct answer: C. New onset of confusion and restlessness
Rationale: New confusion and restlessness can be early
manifestations of inadequate cerebral oxygenation and
worsening hypoxemia. Although an elevated respiratory rate
and anxiety can occur with respiratory distress, altered mental
status is a particularly concerning sign because the brain is
highly sensitive to decreased oxygen delivery. The nurse should
immediately reassess airway, breathing, oxygen saturation,
,lung sounds, and other indicators of respiratory compromise
and initiate appropriate interventions.
2. Which client should the nurse assess first?
A. A client with chronic arthritis reporting pain of 6/10
B. A client requesting assistance with bathing
C. A postoperative client requesting an antiemetic
D. A client with pneumonia who has a new respiratory rate of
32/min
Correct answer: D. A client with pneumonia who has a new
respiratory rate of 32/min
Rationale: Airway and breathing take priority over less urgent
needs. A respiratory rate of 32/min in a client with pneumonia
indicates significant respiratory compromise and may signal
worsening hypoxemia or impending respiratory failure. The
nurse should immediately assess respiratory status and
oxygenation. Pain, hygiene, and nausea are important but do
not take priority over an acute alteration in breathing.
3. A client is receiving intravenous morphine after surgery.
Which finding is most concerning?
A. Nausea
B. Constipation
,C. Drowsiness
D. Respiratory rate of 8/min
Correct answer: D. Respiratory rate of 8/min
Rationale: Opioids can cause central nervous system depression
and respiratory depression. A respiratory rate of 8/min is
dangerously low and requires immediate assessment and
intervention. The nurse should assess the client's level of
consciousness, airway, respiratory effort, and oxygenation and
follow the appropriate protocol for opioid-induced respiratory
depression. Nausea, constipation, and mild drowsiness are
common opioid effects but are less immediately life-
threatening.
4. A nurse is preparing to administer digoxin. Which
assessment finding should cause the nurse to withhold the
medication and notify the provider?
A. Blood pressure of 128/74 mmHg
B. Respiratory rate of 18/min
C. Apical pulse of 54/min
D. Temperature of 37.0°C
Correct answer: C. Apical pulse of 54/min
Rationale: Digoxin can slow the heart rate by increasing vagal
activity and affecting cardiac conduction. Before administering
, digoxin, the nurse should assess the apical pulse for a full
minute. A significant bradycardia is a reason to withhold the
medication and follow institutional parameters for notifying the
provider. The other findings are within expected ranges and do
not independently indicate that digoxin should be withheld.
5. Which laboratory result is most important for the nurse to
monitor in a client receiving warfarin?
A. aPTT
B. Serum sodium
C. Serum creatinine
D. INR
Correct answer: D. INR
Rationale: Warfarin therapy is monitored primarily with the
international normalized ratio (INR), which evaluates the
anticoagulant effect of warfarin. Maintaining the INR within the
prescribed therapeutic range helps balance the risk of
thrombosis against the risk of bleeding. The aPTT is primarily
used to monitor unfractionated heparin therapy rather than
warfarin.
Questions with Correct Answers
(VerifiedAnswers) Plus Rationales 2026 Q&A
Instant Download PDF
1. A nurse is assessing a client who has developed acute
shortness of breath. Which assessment finding requires the
nurse's immediate intervention?
A. Respiratory rate of 22/min
B. Oxygen saturation of 94%
C. New onset of confusion and restlessness
D. Mild anxiety related to dyspnea
Correct answer: C. New onset of confusion and restlessness
Rationale: New confusion and restlessness can be early
manifestations of inadequate cerebral oxygenation and
worsening hypoxemia. Although an elevated respiratory rate
and anxiety can occur with respiratory distress, altered mental
status is a particularly concerning sign because the brain is
highly sensitive to decreased oxygen delivery. The nurse should
immediately reassess airway, breathing, oxygen saturation,
,lung sounds, and other indicators of respiratory compromise
and initiate appropriate interventions.
2. Which client should the nurse assess first?
A. A client with chronic arthritis reporting pain of 6/10
B. A client requesting assistance with bathing
C. A postoperative client requesting an antiemetic
D. A client with pneumonia who has a new respiratory rate of
32/min
Correct answer: D. A client with pneumonia who has a new
respiratory rate of 32/min
Rationale: Airway and breathing take priority over less urgent
needs. A respiratory rate of 32/min in a client with pneumonia
indicates significant respiratory compromise and may signal
worsening hypoxemia or impending respiratory failure. The
nurse should immediately assess respiratory status and
oxygenation. Pain, hygiene, and nausea are important but do
not take priority over an acute alteration in breathing.
3. A client is receiving intravenous morphine after surgery.
Which finding is most concerning?
A. Nausea
B. Constipation
,C. Drowsiness
D. Respiratory rate of 8/min
Correct answer: D. Respiratory rate of 8/min
Rationale: Opioids can cause central nervous system depression
and respiratory depression. A respiratory rate of 8/min is
dangerously low and requires immediate assessment and
intervention. The nurse should assess the client's level of
consciousness, airway, respiratory effort, and oxygenation and
follow the appropriate protocol for opioid-induced respiratory
depression. Nausea, constipation, and mild drowsiness are
common opioid effects but are less immediately life-
threatening.
4. A nurse is preparing to administer digoxin. Which
assessment finding should cause the nurse to withhold the
medication and notify the provider?
A. Blood pressure of 128/74 mmHg
B. Respiratory rate of 18/min
C. Apical pulse of 54/min
D. Temperature of 37.0°C
Correct answer: C. Apical pulse of 54/min
Rationale: Digoxin can slow the heart rate by increasing vagal
activity and affecting cardiac conduction. Before administering
, digoxin, the nurse should assess the apical pulse for a full
minute. A significant bradycardia is a reason to withhold the
medication and follow institutional parameters for notifying the
provider. The other findings are within expected ranges and do
not independently indicate that digoxin should be withheld.
5. Which laboratory result is most important for the nurse to
monitor in a client receiving warfarin?
A. aPTT
B. Serum sodium
C. Serum creatinine
D. INR
Correct answer: D. INR
Rationale: Warfarin therapy is monitored primarily with the
international normalized ratio (INR), which evaluates the
anticoagulant effect of warfarin. Maintaining the INR within the
prescribed therapeutic range helps balance the risk of
thrombosis against the risk of bleeding. The aPTT is primarily
used to monitor unfractionated heparin therapy rather than
warfarin.
