,Arizona College NUR 445 Exam 1 | Acute & Chronic
Health Disruptions in Adults III (2026) Q&A
1. A nurse is caring for a patient whose condition requires prioritization, communication,
safety, and evidence-based clinical judgment. Which action best demonstrates clinical
judgment when several abnormal findings are identified?
A) Document every finding before taking action
B) Address the most immediately life-threatening problem first
C) Ask the family which problem should receive priority
D) Wait until laboratory results are available before intervening
Correct Answer: Address the most immediately life-threatening problem first
Rationale: Clinical judgment requires recognizing threats to airway, breathing,
circulation, and neurologic status. Immediate threats should be addressed while additional
data are collected. Documenting before acting or waiting for labs delays necessary
intervention.
2. A nurse is caring for a deteriorating adult patient with multiple acute conditions. Which
assessment finding should the nurse recognize as the highest priority?
A) Mild chronic back discomfort rated 3/10
B) Decreased appetite during the previous meal
C) New confusion with oxygen saturation of 82%
D) Difficulty sleeping during the previous night
Correct Answer: New confusion with oxygen saturation of 82%
,Rationale: Severe hypoxemia can rapidly compromise neurologic and cardiac function.
New confusion may indicate inadequate oxygen delivery to the brain. Airway and breathing
concerns take priority over stable comfort concerns.
3. Why is trending vital signs particularly important when monitoring patients with acute
and chronic health disruptions?
A) It eliminates the need for physical assessment
B) It determines the patient's insurance classification
C) It helps identify clinically significant changes over time
D) It guarantees that complications will not develop
Correct Answer: It helps identify clinically significant changes over time
Rationale: Trends can reveal deterioration before a single abnormal value becomes
dramatic. Changes over time provide more clinical meaning than isolated measurements.
Trending does not eliminate the need for assessment or guarantee absence of
complications.
4. A patient suddenly becomes difficult to arouse and develops shallow respirations. What
is the nurse's priority action?
A) Offer oral fluids and reassess in thirty minutes
B) Encourage ambulation to stimulate circulation
C) Place the patient flat and leave the room
D) Immediately assess airway and breathing while calling for assistance
Correct Answer: Immediately assess airway and breathing while calling for assistance
, Rationale: Sudden decrease in level of consciousness with shallow respirations indicates
impending respiratory failure. Airway and breathing are the priority. Offering fluids or
ambulating would delay necessary intervention.
5. A nurse is performing an initial assessment of a newly admitted client. Which action
should the nurse perform first?
A) Obtain a complete health history
B) Assess airway, breathing, and circulation
C) Review the medication administration record
D) Perform a head-to-toe physical examination
Correct Answer: Assess airway, breathing, and circulation
Rationale: The ABCs (airway, breathing, circulation) are always the first priority in any
patient assessment. A complete history, medication review, and head-to-toe examination
follow initial stabilization. Immediate threats to life must be identified and addressed first.
6. A patient with chronic COPD becomes increasingly confused and has an SpO₂ of 85% on
2 L/min via nasal cannula. What is the nurse's first action?
A) Increase oxygen to 6 L/min
B) Assess airway patency and respiratory effort
C) Document the finding and continue monitoring
D) Administer a prescribed bronchodilator
Correct Answer: Assess airway patency and respiratory effort
Rationale: Before adjusting oxygen or administering medications, the nurse must assess
the airway and breathing to determine the cause of deterioration. Assessment precedes
Health Disruptions in Adults III (2026) Q&A
1. A nurse is caring for a patient whose condition requires prioritization, communication,
safety, and evidence-based clinical judgment. Which action best demonstrates clinical
judgment when several abnormal findings are identified?
A) Document every finding before taking action
B) Address the most immediately life-threatening problem first
C) Ask the family which problem should receive priority
D) Wait until laboratory results are available before intervening
Correct Answer: Address the most immediately life-threatening problem first
Rationale: Clinical judgment requires recognizing threats to airway, breathing,
circulation, and neurologic status. Immediate threats should be addressed while additional
data are collected. Documenting before acting or waiting for labs delays necessary
intervention.
2. A nurse is caring for a deteriorating adult patient with multiple acute conditions. Which
assessment finding should the nurse recognize as the highest priority?
A) Mild chronic back discomfort rated 3/10
B) Decreased appetite during the previous meal
C) New confusion with oxygen saturation of 82%
D) Difficulty sleeping during the previous night
Correct Answer: New confusion with oxygen saturation of 82%
,Rationale: Severe hypoxemia can rapidly compromise neurologic and cardiac function.
New confusion may indicate inadequate oxygen delivery to the brain. Airway and breathing
concerns take priority over stable comfort concerns.
3. Why is trending vital signs particularly important when monitoring patients with acute
and chronic health disruptions?
A) It eliminates the need for physical assessment
B) It determines the patient's insurance classification
C) It helps identify clinically significant changes over time
D) It guarantees that complications will not develop
Correct Answer: It helps identify clinically significant changes over time
Rationale: Trends can reveal deterioration before a single abnormal value becomes
dramatic. Changes over time provide more clinical meaning than isolated measurements.
Trending does not eliminate the need for assessment or guarantee absence of
complications.
4. A patient suddenly becomes difficult to arouse and develops shallow respirations. What
is the nurse's priority action?
A) Offer oral fluids and reassess in thirty minutes
B) Encourage ambulation to stimulate circulation
C) Place the patient flat and leave the room
D) Immediately assess airway and breathing while calling for assistance
Correct Answer: Immediately assess airway and breathing while calling for assistance
, Rationale: Sudden decrease in level of consciousness with shallow respirations indicates
impending respiratory failure. Airway and breathing are the priority. Offering fluids or
ambulating would delay necessary intervention.
5. A nurse is performing an initial assessment of a newly admitted client. Which action
should the nurse perform first?
A) Obtain a complete health history
B) Assess airway, breathing, and circulation
C) Review the medication administration record
D) Perform a head-to-toe physical examination
Correct Answer: Assess airway, breathing, and circulation
Rationale: The ABCs (airway, breathing, circulation) are always the first priority in any
patient assessment. A complete history, medication review, and head-to-toe examination
follow initial stabilization. Immediate threats to life must be identified and addressed first.
6. A patient with chronic COPD becomes increasingly confused and has an SpO₂ of 85% on
2 L/min via nasal cannula. What is the nurse's first action?
A) Increase oxygen to 6 L/min
B) Assess airway patency and respiratory effort
C) Document the finding and continue monitoring
D) Administer a prescribed bronchodilator
Correct Answer: Assess airway patency and respiratory effort
Rationale: Before adjusting oxygen or administering medications, the nurse must assess
the airway and breathing to determine the cause of deterioration. Assessment precedes
