,NUR 210 Clinical Judgment Assessment Medical-Surgical Nursing II
Questions And Answers 2026/2027 Jersey College
Q1. A patient admitted with vomiting and diarrhea has blood
pressure 86/48 mm Hg, heart rate 124/min, dry mucous membranes,
and urine output of 15 mL/hr. Which hypothesis should the nurse
prioritize?
A) Significant fluid volume deficit causing impaired tissue perfusion
B) Fluid volume excess
C) Stable hydration status
D) Chronic hypertension
Correct Answer: A) Significant fluid volume deficit causing impaired tissue
perfusion
Rationale: Hypotension, tachycardia, dehydration, and oliguria indicate
reduced circulating volume with compromised organ perfusion.
Q2. A patient has serum potassium 6.8 mEq/L, weakness, and tall
peaked T waves. Which action has priority?
A) Encourage ambulation
B) Initiate cardiac monitoring and treatment for severe hyperkalemia
C) Increase dietary potassium
D) Reassess in four hours
Correct Answer: B) Initiate cardiac monitoring and treatment for severe
hyperkalemia
Rationale: Severe hyperkalemia with electrocardiographic changes can
rapidly cause lethal cardiac dysrhythmias.
Q3. A patient with sodium 117 mEq/L becomes confused and begins
having generalized muscle twitching. Which complication should the
nurse anticipate?
A) Hyperglycemia
B) Constipation
C) Seizure activity related to severe hyponatremia
D) Osteoporosis
Correct Answer: C) Seizure activity related to severe hyponatremia
Rationale: Severe hyponatremia can cause cerebral edema, neurologic
deterioration, and seizures.
,Q4. A patient with suspected infection has temperature 39.3°C,
heart rate 132/min, blood pressure 80/42 mm Hg, lactate 5.1
mmol/L, and increasing confusion. Which action best reflects
appropriate clinical judgment?
A) Treat the fever and reassess tomorrow
B) Encourage oral fluids only
C) Wait for final culture results before intervening
D) Escalate sepsis treatment rapidly while supporting circulation and organ
perfusion
Correct Answer: D) Escalate sepsis treatment rapidly while supporting
circulation and organ perfusion
Rationale: Infection with hypotension, elevated lactate, and altered mental
status indicates severe systemic illness and inadequate tissue perfusion.
Q5. Which trend best indicates improving perfusion in a patient
being treated for shock?
A) Urine output increases while mental status and blood pressure improve
B) Lactate rises progressively
C) Skin becomes increasingly mottled
D) Urine output falls
Correct Answer: A) Urine output increases while mental status and blood
pressure improve
Rationale: Improved renal output, cognition, and hemodynamics indicate
restoration of organ perfusion.
Q6. A patient taking a loop diuretic develops potassium 2.7 mEq/L
and frequent ventricular ectopy. Which intervention should be
prioritized?
A) Restrict potassium
B) Correct the potassium abnormality and monitor cardiac rhythm
C) Encourage strenuous exercise
D) Discontinue all cardiac monitoring
Correct Answer: B) Correct the potassium abnormality and monitor cardiac
rhythm
Rationale: Significant hypokalemia can precipitate dangerous ventricular
dysrhythmias.
, Q7. A patient with fluid overload develops worsening crackles,
respiratory rate 32/min, and oxygen saturation 86%. Which problem
has the highest priority?
A) Peripheral edema
B) Daily weight gain
C) Impaired oxygenation from pulmonary fluid accumulation
D) Activity intolerance
Correct Answer: C) Impaired oxygenation from pulmonary fluid accumulation
Rationale: Pulmonary congestion can impair gas exchange and becomes
the immediate priority when oxygenation deteriorates.
Q8. A patient with severe sepsis develops acute kidney injury,
worsening hypoxemia, hepatic dysfunction, and altered
consciousness. Which complication is most consistent with this
pattern?
A) Simple dehydration
B) Localized infection
C) Stable recovery
D) Multiple organ dysfunction syndrome
Correct Answer: D) Multiple organ dysfunction syndrome
Rationale: Progressive dysfunction of several organ systems after severe
systemic illness is characteristic of MODS.
Q9. A patient receiving an IV opioid becomes difficult to arouse with
respirations of 6/min. Which action should occur first?
A) Support airway and ventilation and initiate opioid-reversal treatment as
indicated
B) Obtain a new pain score
C) Encourage oral fluids
D) Allow the patient to sleep
Correct Answer: A) Support airway and ventilation and initiate opioid-reversal
treatment as indicated
Rationale: Opioid-induced respiratory depression is an immediate airway
and breathing emergency.
Q10. Which patient should the nurse assess first?
Questions And Answers 2026/2027 Jersey College
Q1. A patient admitted with vomiting and diarrhea has blood
pressure 86/48 mm Hg, heart rate 124/min, dry mucous membranes,
and urine output of 15 mL/hr. Which hypothesis should the nurse
prioritize?
A) Significant fluid volume deficit causing impaired tissue perfusion
B) Fluid volume excess
C) Stable hydration status
D) Chronic hypertension
Correct Answer: A) Significant fluid volume deficit causing impaired tissue
perfusion
Rationale: Hypotension, tachycardia, dehydration, and oliguria indicate
reduced circulating volume with compromised organ perfusion.
Q2. A patient has serum potassium 6.8 mEq/L, weakness, and tall
peaked T waves. Which action has priority?
A) Encourage ambulation
B) Initiate cardiac monitoring and treatment for severe hyperkalemia
C) Increase dietary potassium
D) Reassess in four hours
Correct Answer: B) Initiate cardiac monitoring and treatment for severe
hyperkalemia
Rationale: Severe hyperkalemia with electrocardiographic changes can
rapidly cause lethal cardiac dysrhythmias.
Q3. A patient with sodium 117 mEq/L becomes confused and begins
having generalized muscle twitching. Which complication should the
nurse anticipate?
A) Hyperglycemia
B) Constipation
C) Seizure activity related to severe hyponatremia
D) Osteoporosis
Correct Answer: C) Seizure activity related to severe hyponatremia
Rationale: Severe hyponatremia can cause cerebral edema, neurologic
deterioration, and seizures.
,Q4. A patient with suspected infection has temperature 39.3°C,
heart rate 132/min, blood pressure 80/42 mm Hg, lactate 5.1
mmol/L, and increasing confusion. Which action best reflects
appropriate clinical judgment?
A) Treat the fever and reassess tomorrow
B) Encourage oral fluids only
C) Wait for final culture results before intervening
D) Escalate sepsis treatment rapidly while supporting circulation and organ
perfusion
Correct Answer: D) Escalate sepsis treatment rapidly while supporting
circulation and organ perfusion
Rationale: Infection with hypotension, elevated lactate, and altered mental
status indicates severe systemic illness and inadequate tissue perfusion.
Q5. Which trend best indicates improving perfusion in a patient
being treated for shock?
A) Urine output increases while mental status and blood pressure improve
B) Lactate rises progressively
C) Skin becomes increasingly mottled
D) Urine output falls
Correct Answer: A) Urine output increases while mental status and blood
pressure improve
Rationale: Improved renal output, cognition, and hemodynamics indicate
restoration of organ perfusion.
Q6. A patient taking a loop diuretic develops potassium 2.7 mEq/L
and frequent ventricular ectopy. Which intervention should be
prioritized?
A) Restrict potassium
B) Correct the potassium abnormality and monitor cardiac rhythm
C) Encourage strenuous exercise
D) Discontinue all cardiac monitoring
Correct Answer: B) Correct the potassium abnormality and monitor cardiac
rhythm
Rationale: Significant hypokalemia can precipitate dangerous ventricular
dysrhythmias.
, Q7. A patient with fluid overload develops worsening crackles,
respiratory rate 32/min, and oxygen saturation 86%. Which problem
has the highest priority?
A) Peripheral edema
B) Daily weight gain
C) Impaired oxygenation from pulmonary fluid accumulation
D) Activity intolerance
Correct Answer: C) Impaired oxygenation from pulmonary fluid accumulation
Rationale: Pulmonary congestion can impair gas exchange and becomes
the immediate priority when oxygenation deteriorates.
Q8. A patient with severe sepsis develops acute kidney injury,
worsening hypoxemia, hepatic dysfunction, and altered
consciousness. Which complication is most consistent with this
pattern?
A) Simple dehydration
B) Localized infection
C) Stable recovery
D) Multiple organ dysfunction syndrome
Correct Answer: D) Multiple organ dysfunction syndrome
Rationale: Progressive dysfunction of several organ systems after severe
systemic illness is characteristic of MODS.
Q9. A patient receiving an IV opioid becomes difficult to arouse with
respirations of 6/min. Which action should occur first?
A) Support airway and ventilation and initiate opioid-reversal treatment as
indicated
B) Obtain a new pain score
C) Encourage oral fluids
D) Allow the patient to sleep
Correct Answer: A) Support airway and ventilation and initiate opioid-reversal
treatment as indicated
Rationale: Opioid-induced respiratory depression is an immediate airway
and breathing emergency.
Q10. Which patient should the nurse assess first?
