NUR 555 ALL QUESTIONS AND ANSWERS | LATEST
UPDATED QUESTIONS | A+ GRADED | COMPREHENSIVE
EXAM GUIDE 2026&2027
1. A nurse is assessing a hospitalized adult who suddenly becomes restless and disoriented.
The patient has a respiratory rate of 30/min and an oxygen saturation of 86% on room air.
Which action should the nurse take FIRST?
A. Reorient the patient to the current date and location
B. Apply supplemental oxygen and assess the patient's respiratory status
C. Administer the prescribed antianxiety medication
D. Document the change as acute confusion
Answer: B
The immediate priority is correcting possible hypoxemia because impaired oxygenation can
rapidly cause acute mental-status changes. The nurse should support oxygenation while
continuing a focused respiratory assessment.
2. During medication reconciliation, a patient reports taking two medications with similar
names prescribed by different providers. What should the nurse do first?
A. Determine the indication and prescribed dose of each medication
B. Tell the patient to discontinue the newer medication
C. Document both medications as home medications
D. Ask the pharmacy to remove one medication from the record
Answer: A
The nurse must first establish what each medication is, why it is being taken, and the
prescribed regimen before determining whether duplication or an interaction exists.
3. A patient with chronic heart failure reports a 2.5-kg weight gain over the past three
days. Which finding most strongly supports fluid volume excess?
A. Dry oral mucosa
B. Flat neck veins
C. Bilateral dependent edema
D. Decreased blood pressure with tachycardia
Answer: C
Rapid weight gain accompanied by dependent edema is consistent with fluid retention, a
common manifestation of worsening heart failure.
,4. A postoperative patient suddenly develops dyspnea, pleuritic chest pain, tachycardia,
and oxygen saturation of 89%. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Fluid overload
D. Pneumonia
Answer: B
The abrupt onset of dyspnea, pleuritic chest pain, tachycardia, and hypoxemia is highly
concerning for pulmonary embolism and requires immediate assessment and intervention.
5. A nurse is caring for a patient receiving an intravenous medication that can cause tissue
injury if extravasation occurs. The IV site becomes swollen and painful. What is the nurse's
priority action?
A. Increase the infusion rate
B. Flush the catheter vigorously
C. Stop the infusion
D. Apply pressure over the site
Answer: C
Stopping the infusion prevents additional medication from entering the surrounding tissue.
The nurse should then follow the medication-specific extravasation protocol.
6. A patient with diabetes is awake, diaphoretic, trembling, and reports feeling extremely
hungry. Which condition should the nurse suspect?
A. Hyperglycemia
B. Hypoglycemia
C. Diabetic ketoacidosis
D. Hyperosmolar hyperglycemic state
Answer: B
Diaphoresis, tremors, hunger, and adrenergic symptoms are classic early manifestations of
hypoglycemia.
7. A nurse receives four patient assignments at the beginning of a shift. Which patient
should be assessed first?
A. A patient reporting pain rated 7/10 after surgery
B. A patient awaiting discharge instructions
,C. A patient with stable chronic kidney disease requesting assistance with bathing
D. A patient with new-onset stridor after extubation
Answer: D
Stridor after extubation may indicate upper-airway obstruction and threatens airway
patency. Airway problems take priority over pain, hygiene, and discharge needs.
8. A patient with suspected infection has a temperature of 39.2°C, heart rate of 124/min,
respiratory rate of 28/min, and altered mental status. Which concern should receive
immediate attention?
A. Possible sepsis with impaired perfusion
B. Expected response to fever
C. Mild dehydration only
D. Isolated anxiety
Answer: A
Fever, tachycardia, tachypnea, and altered mental status can indicate systemic infection with
organ dysfunction. Prompt recognition and escalation are essential.
9. A nurse is teaching a patient how to use an incentive spirometer after surgery. Which
instruction is most appropriate?
A. Exhale forcefully into the device
B. Use the device only when shortness of breath occurs
C. Inhale slowly and deeply through the mouthpiece
D. Perform one breath every four hours
Answer: C
Slow, sustained inhalation through the mouthpiece promotes lung expansion and helps
reduce postoperative pulmonary complications.
10. A patient receiving opioid analgesia has a respiratory rate of 7/min and is difficult to
arouse. What is the nurse's priority?
A. Document the expected sedative effect
B. Support airway and breathing and initiate emergency intervention
C. Offer oral fluids
D. Encourage the patient to ambulate
Answer: B
, Severe respiratory depression following opioid administration is an emergency. Airway and
ventilation must be supported immediately while opioid reversal and emergency protocols
are considered.
11. A patient with chronic obstructive pulmonary disease is receiving oxygen therapy.
Which nursing action is appropriate?
A. Titrate oxygen according to the prescribed target and clinical condition
B. Discontinue oxygen whenever the patient becomes sleepy
C. Administer the highest available oxygen concentration routinely
D. Restrict oxygen because all oxygen is contraindicated in COPD
Answer: A
Patients with COPD may require carefully titrated oxygen therapy. Oxygen should not be
withheld, but excessive oxygen administration should be avoided when a prescribed target
range is available.
12. A nurse is assessing a patient with suspected hypovolemic shock. Which finding is most
concerning?
A. Warm skin and bounding pulses
B. Bradycardia with hypertension
C. Cool skin, tachycardia, and decreased urine output
D. Increased urine output with normal mental status
Answer: C
Peripheral vasoconstriction, tachycardia, oliguria, and altered perfusion are characteristic
findings of significant volume depletion and shock.
13. A patient receiving a blood transfusion develops chills, fever, and back pain shortly
after the transfusion begins. What should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen and continue
D. Flush the blood tubing with the blood product
Answer: B
Fever, chills, and back pain may indicate an acute transfusion reaction. The transfusion must
be stopped immediately and the facility's transfusion-reaction protocol initiated.
14. A patient with renal impairment is prescribed a medication primarily eliminated by the
kidneys. Which nursing consideration is most important?
UPDATED QUESTIONS | A+ GRADED | COMPREHENSIVE
EXAM GUIDE 2026&2027
1. A nurse is assessing a hospitalized adult who suddenly becomes restless and disoriented.
The patient has a respiratory rate of 30/min and an oxygen saturation of 86% on room air.
Which action should the nurse take FIRST?
A. Reorient the patient to the current date and location
B. Apply supplemental oxygen and assess the patient's respiratory status
C. Administer the prescribed antianxiety medication
D. Document the change as acute confusion
Answer: B
The immediate priority is correcting possible hypoxemia because impaired oxygenation can
rapidly cause acute mental-status changes. The nurse should support oxygenation while
continuing a focused respiratory assessment.
2. During medication reconciliation, a patient reports taking two medications with similar
names prescribed by different providers. What should the nurse do first?
A. Determine the indication and prescribed dose of each medication
B. Tell the patient to discontinue the newer medication
C. Document both medications as home medications
D. Ask the pharmacy to remove one medication from the record
Answer: A
The nurse must first establish what each medication is, why it is being taken, and the
prescribed regimen before determining whether duplication or an interaction exists.
3. A patient with chronic heart failure reports a 2.5-kg weight gain over the past three
days. Which finding most strongly supports fluid volume excess?
A. Dry oral mucosa
B. Flat neck veins
C. Bilateral dependent edema
D. Decreased blood pressure with tachycardia
Answer: C
Rapid weight gain accompanied by dependent edema is consistent with fluid retention, a
common manifestation of worsening heart failure.
,4. A postoperative patient suddenly develops dyspnea, pleuritic chest pain, tachycardia,
and oxygen saturation of 89%. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Fluid overload
D. Pneumonia
Answer: B
The abrupt onset of dyspnea, pleuritic chest pain, tachycardia, and hypoxemia is highly
concerning for pulmonary embolism and requires immediate assessment and intervention.
5. A nurse is caring for a patient receiving an intravenous medication that can cause tissue
injury if extravasation occurs. The IV site becomes swollen and painful. What is the nurse's
priority action?
A. Increase the infusion rate
B. Flush the catheter vigorously
C. Stop the infusion
D. Apply pressure over the site
Answer: C
Stopping the infusion prevents additional medication from entering the surrounding tissue.
The nurse should then follow the medication-specific extravasation protocol.
6. A patient with diabetes is awake, diaphoretic, trembling, and reports feeling extremely
hungry. Which condition should the nurse suspect?
A. Hyperglycemia
B. Hypoglycemia
C. Diabetic ketoacidosis
D. Hyperosmolar hyperglycemic state
Answer: B
Diaphoresis, tremors, hunger, and adrenergic symptoms are classic early manifestations of
hypoglycemia.
7. A nurse receives four patient assignments at the beginning of a shift. Which patient
should be assessed first?
A. A patient reporting pain rated 7/10 after surgery
B. A patient awaiting discharge instructions
,C. A patient with stable chronic kidney disease requesting assistance with bathing
D. A patient with new-onset stridor after extubation
Answer: D
Stridor after extubation may indicate upper-airway obstruction and threatens airway
patency. Airway problems take priority over pain, hygiene, and discharge needs.
8. A patient with suspected infection has a temperature of 39.2°C, heart rate of 124/min,
respiratory rate of 28/min, and altered mental status. Which concern should receive
immediate attention?
A. Possible sepsis with impaired perfusion
B. Expected response to fever
C. Mild dehydration only
D. Isolated anxiety
Answer: A
Fever, tachycardia, tachypnea, and altered mental status can indicate systemic infection with
organ dysfunction. Prompt recognition and escalation are essential.
9. A nurse is teaching a patient how to use an incentive spirometer after surgery. Which
instruction is most appropriate?
A. Exhale forcefully into the device
B. Use the device only when shortness of breath occurs
C. Inhale slowly and deeply through the mouthpiece
D. Perform one breath every four hours
Answer: C
Slow, sustained inhalation through the mouthpiece promotes lung expansion and helps
reduce postoperative pulmonary complications.
10. A patient receiving opioid analgesia has a respiratory rate of 7/min and is difficult to
arouse. What is the nurse's priority?
A. Document the expected sedative effect
B. Support airway and breathing and initiate emergency intervention
C. Offer oral fluids
D. Encourage the patient to ambulate
Answer: B
, Severe respiratory depression following opioid administration is an emergency. Airway and
ventilation must be supported immediately while opioid reversal and emergency protocols
are considered.
11. A patient with chronic obstructive pulmonary disease is receiving oxygen therapy.
Which nursing action is appropriate?
A. Titrate oxygen according to the prescribed target and clinical condition
B. Discontinue oxygen whenever the patient becomes sleepy
C. Administer the highest available oxygen concentration routinely
D. Restrict oxygen because all oxygen is contraindicated in COPD
Answer: A
Patients with COPD may require carefully titrated oxygen therapy. Oxygen should not be
withheld, but excessive oxygen administration should be avoided when a prescribed target
range is available.
12. A nurse is assessing a patient with suspected hypovolemic shock. Which finding is most
concerning?
A. Warm skin and bounding pulses
B. Bradycardia with hypertension
C. Cool skin, tachycardia, and decreased urine output
D. Increased urine output with normal mental status
Answer: C
Peripheral vasoconstriction, tachycardia, oliguria, and altered perfusion are characteristic
findings of significant volume depletion and shock.
13. A patient receiving a blood transfusion develops chills, fever, and back pain shortly
after the transfusion begins. What should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen and continue
D. Flush the blood tubing with the blood product
Answer: B
Fever, chills, and back pain may indicate an acute transfusion reaction. The transfusion must
be stopped immediately and the facility's transfusion-reaction protocol initiated.
14. A patient with renal impairment is prescribed a medication primarily eliminated by the
kidneys. Which nursing consideration is most important?
