NUR 1020 vSim case and Eva Madison
with correct questions and verified
answers with rationale updated 2026
new!!
Section 1: Assessment & Data Collection (Questions 1–20)
1. During the initial interview with Eva Madison, which statement should the nurse identify as the
priority complaint?
A. "I feel really tired all the time."
B. "I have been coughing up yellow phlegm."
C. "I'm having trouble catching my breath when I walk to the kitchen."
D. "My chest hurts a little when I take a deep breath."
Answer: C
Rationale: Difficulty breathing represents an immediate threat to airway and breathing (ABCs). While
fatigue and cough are symptoms, dyspnea indicates compromised gas exchange and requires
priority attention.
2. The nurse auscultates Eva's lung sounds. Which finding is consistent with pneumonia?
A. Wheezing in bilateral bases.
B. Crackles (rales) in the right lower lobe.
C. Stridor in the upper airway.
D. Diminished breath sounds bilaterally with hyperresonance.
Answer: B
Rationale: Crackles indicate fluid in the alveoli, which is characteristic of pneumonia. Wheezing is
more common in asthma/COPD; stridor indicates upper airway obstruction; hyperresonance
suggests emphysema or pneumothorax.
3. Eva's oxygen saturation is 92% on room air. What is the nurse's immediate action?
,A. Document the finding as within normal limits.
B. Administer oxygen via nasal cannula per protocol.
C. Encourage Eva to take deep breaths and reassess in 15 minutes.
D. Notify the provider immediately without intervention.
Answer: B
Rationale: An SpO2 of 92% is below the target range (usually >94%). The nurse should initiate oxygen
therapy to improve saturation before the provider is notified, following standing orders or protocols.
4. Which vital sign finding supports the diagnosis of an active infection in Eva?
A. Temperature 98.6°F (37°C).
B. Heart rate 88 bpm.
C. Temperature 101.4°F (38.6°C).
D. Blood pressure 120/78 mmHg.
Answer: C
Rationale: Fever is a systemic response to infection. A temperature of 101.4°F indicates pyrexia
consistent with pneumonia.
5. The nurse observes Eva's skin color. Which finding would indicate severe hypoxia?
A. Pallor.
B. Cyanosis of the nail beds.
C. Erythema over the cheeks.
D. Jaundice of the sclera.
Answer: B
Rationale: Cyanosis is a late sign of hypoxia, indicating low oxygen levels in the blood. Pallor may
indicate anemia; erythema may indicate fever; jaundice indicates liver dysfunction.
6. Eva reports a "productive cough." What question should the nurse ask to gather more data?
A. "How often do you cough?"
B. "What color and consistency is the sputum?"
C. "Does the cough happen at night?"
D. "Have you tried cough drops?"
Answer: B
,Rationale: The color and consistency of sputum help determine the nature of the infection (e.g.,
yellow/green suggests bacterial; clear suggests viral). This is high-value assessment data.
7. When assessing Eva's pain, the nurse notes a score of 6/10 related to coughing. How does this
pain affect care?
A. Pain medication should be avoided to prevent respiratory depression.
B. The pain will prevent Eva from taking deep breaths, increasing atelectasis risk.
C. The pain is normal and requires no intervention.
D. The pain suggests rib fracture, requiring an X-ray immediately.
Answer: B
Rationale: Pain inhibits deep breathing and effective coughing, which can lead to airway obstruction
and atelectasis. Pain management is essential for respiratory clearance.
8. Which physical assessment finding suggests Eva is using accessory muscles?
A. Flaring of the nostrils and retractions.
B. Equal rise and fall of the chest.
C. Diaphragmatic breathing.
D. Relaxed neck muscles.
Answer: A
Rationale: Use of accessory muscles, nasal flaring, and retractions indicate respiratory distress and
increased work of breathing.
9. Eva's respiratory rate is 24 breaths per minute. How should the nurse document this?
A. Tachypnea.
B. Bradypnea.
C. Hypopnea.
D. Apnea.
Answer: A
Rationale: Tachypnea is a respiratory rate >20 breaths/min in adults. It is a compensatory
mechanism for hypoxia or fever.
10. Which history finding places Eva at higher risk for pneumonia?
A. Non-smoker.
, B. Regular exercise routine.
C. History of smoking cigarettes.
D. Balanced diet.
Answer: C
Rationale: Smoking damages cilia and mucociliary clearance mechanisms, increasing susceptibility to
respiratory infections.
11. The nurse assesses Eva's hydration status. Which finding indicates dehydration?
A. Moist mucous membranes.
B. Elastic skin turgor.
C. Dry mucous membranes and poor skin turgor.
D. Capillary refill <2 seconds.
Answer: C
Rationale: Fever and increased metabolic rate can lead to fluid loss. Dry mucous membranes and
tenting skin indicate dehydration, which can thicken secretions.
12. Eva states she lives alone. Why is this significant?
A. It is not relevant to her respiratory status.
B. It may impact her ability to perform ADLs and safety at home.
C. It suggests she has a high income.
D. It means she will recover faster.
Answer: B
Rationale: Living alone affects discharge planning, safety, ability to manage medications, and risk for
falls or neglect of self-care during illness.
13. Which laboratory value is likely elevated in Eva due to infection?
A. Hemoglobin.
B. White Blood Cell (WBC) count.
C. Platelet count.
C. Sodium level.
Answer: B
Rationale: Leukocytosis (elevated WBC) is a common response to bacterial infection.
with correct questions and verified
answers with rationale updated 2026
new!!
Section 1: Assessment & Data Collection (Questions 1–20)
1. During the initial interview with Eva Madison, which statement should the nurse identify as the
priority complaint?
A. "I feel really tired all the time."
B. "I have been coughing up yellow phlegm."
C. "I'm having trouble catching my breath when I walk to the kitchen."
D. "My chest hurts a little when I take a deep breath."
Answer: C
Rationale: Difficulty breathing represents an immediate threat to airway and breathing (ABCs). While
fatigue and cough are symptoms, dyspnea indicates compromised gas exchange and requires
priority attention.
2. The nurse auscultates Eva's lung sounds. Which finding is consistent with pneumonia?
A. Wheezing in bilateral bases.
B. Crackles (rales) in the right lower lobe.
C. Stridor in the upper airway.
D. Diminished breath sounds bilaterally with hyperresonance.
Answer: B
Rationale: Crackles indicate fluid in the alveoli, which is characteristic of pneumonia. Wheezing is
more common in asthma/COPD; stridor indicates upper airway obstruction; hyperresonance
suggests emphysema or pneumothorax.
3. Eva's oxygen saturation is 92% on room air. What is the nurse's immediate action?
,A. Document the finding as within normal limits.
B. Administer oxygen via nasal cannula per protocol.
C. Encourage Eva to take deep breaths and reassess in 15 minutes.
D. Notify the provider immediately without intervention.
Answer: B
Rationale: An SpO2 of 92% is below the target range (usually >94%). The nurse should initiate oxygen
therapy to improve saturation before the provider is notified, following standing orders or protocols.
4. Which vital sign finding supports the diagnosis of an active infection in Eva?
A. Temperature 98.6°F (37°C).
B. Heart rate 88 bpm.
C. Temperature 101.4°F (38.6°C).
D. Blood pressure 120/78 mmHg.
Answer: C
Rationale: Fever is a systemic response to infection. A temperature of 101.4°F indicates pyrexia
consistent with pneumonia.
5. The nurse observes Eva's skin color. Which finding would indicate severe hypoxia?
A. Pallor.
B. Cyanosis of the nail beds.
C. Erythema over the cheeks.
D. Jaundice of the sclera.
Answer: B
Rationale: Cyanosis is a late sign of hypoxia, indicating low oxygen levels in the blood. Pallor may
indicate anemia; erythema may indicate fever; jaundice indicates liver dysfunction.
6. Eva reports a "productive cough." What question should the nurse ask to gather more data?
A. "How often do you cough?"
B. "What color and consistency is the sputum?"
C. "Does the cough happen at night?"
D. "Have you tried cough drops?"
Answer: B
,Rationale: The color and consistency of sputum help determine the nature of the infection (e.g.,
yellow/green suggests bacterial; clear suggests viral). This is high-value assessment data.
7. When assessing Eva's pain, the nurse notes a score of 6/10 related to coughing. How does this
pain affect care?
A. Pain medication should be avoided to prevent respiratory depression.
B. The pain will prevent Eva from taking deep breaths, increasing atelectasis risk.
C. The pain is normal and requires no intervention.
D. The pain suggests rib fracture, requiring an X-ray immediately.
Answer: B
Rationale: Pain inhibits deep breathing and effective coughing, which can lead to airway obstruction
and atelectasis. Pain management is essential for respiratory clearance.
8. Which physical assessment finding suggests Eva is using accessory muscles?
A. Flaring of the nostrils and retractions.
B. Equal rise and fall of the chest.
C. Diaphragmatic breathing.
D. Relaxed neck muscles.
Answer: A
Rationale: Use of accessory muscles, nasal flaring, and retractions indicate respiratory distress and
increased work of breathing.
9. Eva's respiratory rate is 24 breaths per minute. How should the nurse document this?
A. Tachypnea.
B. Bradypnea.
C. Hypopnea.
D. Apnea.
Answer: A
Rationale: Tachypnea is a respiratory rate >20 breaths/min in adults. It is a compensatory
mechanism for hypoxia or fever.
10. Which history finding places Eva at higher risk for pneumonia?
A. Non-smoker.
, B. Regular exercise routine.
C. History of smoking cigarettes.
D. Balanced diet.
Answer: C
Rationale: Smoking damages cilia and mucociliary clearance mechanisms, increasing susceptibility to
respiratory infections.
11. The nurse assesses Eva's hydration status. Which finding indicates dehydration?
A. Moist mucous membranes.
B. Elastic skin turgor.
C. Dry mucous membranes and poor skin turgor.
D. Capillary refill <2 seconds.
Answer: C
Rationale: Fever and increased metabolic rate can lead to fluid loss. Dry mucous membranes and
tenting skin indicate dehydration, which can thicken secretions.
12. Eva states she lives alone. Why is this significant?
A. It is not relevant to her respiratory status.
B. It may impact her ability to perform ADLs and safety at home.
C. It suggests she has a high income.
D. It means she will recover faster.
Answer: B
Rationale: Living alone affects discharge planning, safety, ability to manage medications, and risk for
falls or neglect of self-care during illness.
13. Which laboratory value is likely elevated in Eva due to infection?
A. Hemoglobin.
B. White Blood Cell (WBC) count.
C. Platelet count.
C. Sodium level.
Answer: B
Rationale: Leukocytosis (elevated WBC) is a common response to bacterial infection.
