NUR 400 Exam Questions and Answers Fully Solved Latest Update 2025-2026
Which information should the nurse include when stating the "Background" element for SBAR
communication?
A) Current vital signs
B) Chief complaint and medical history
C) Code status and allergies
D) Plan of care and proposed interventions - Answers B) Chief complaint and medical history
A nurse is calling the provider about a postoperative patient who has a blood pressure of 88/50
mmHg, heart rate of 114 bpm, and is reporting dizziness when standing. After presenting the
situation, background, and assessment, which statement best reflects an appropriate
Recommendation?
A. "I just wanted to inform you of the patient's vital signs."
B. "The patient's blood pressure is low, and I'm not sure what to do."
C. "Can we consider holding the patient's antihypertensive medication and administering IV
fluids?"
D. "The patient's condition has changed and seems unstable." - Answers C. "Can we consider
holding the patient's antihypertensive medication and administering IV fluids?"
A nurse is caring for a patient with a highly contagious respiratory virus, which nursing practice
will help prevent the spread of the virus through the portal of exit?
A. Discarding all used tissues into the trash can
B. Allowing supervised ambulation in the hallway
C. Keeping the patient's bathroom door closed
D. Having the patient cover their mouth while coughing - Answers D. Having the patient cover
their mouth while coughing
A nurse is caring for a client with a wound infected with MRSA. Which of the following infection
control precautions should the nurse implement?
,A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only - Answers C. Contact precautions
A nurse is preparing to insert a peripheral IV catheter for a patient in the emergency department.
Which aseptic technique should the nurse use?
A) Medical asepsis
B) Surgical asepsis
C) Sterilization of all equipment and the patient's entire arm
D) No aseptic technique is needed - Answers A) Medical asepsis
During inspection of a patient's lower extremities, the nurse notes several findings. Which of the
following requires priority intervention?
A. Scattered bruising on the shins
B. Slight bilateral ankle edema in the evening
C. Pale, cool skin with a shiny appearance and loss of hair on the legs
D. A 1+ dorsalis pedis pulse bilaterally - Answers C. Pale, cool skin with a shiny appearance and
loss of hair on the legs
A nurse is assessing a client admitted with abdominal pain. Which of the following client
statements should the nurse document as subjective data?
A. "The client's abdomen is distended."
B. "The client winces during palpation of the right lower quadrant."
C. "Client states, 'My stomach hurts really bad and I feel nauseous.'"
D. "The client's temperature is 101.2°F (38.4°C)." - Answers C. "Client states, 'My stomach hurts
really bad and I feel nauseous.'"
, A nurse is preparing to administer an antihypertensive medication to a patient. Which of the
following vital signs should the nurse assess before giving the medication?
A) Body temperature
B) Respiratory rate
C) Blood pressure
D) Heart rate - Answers C) Blood pressure
A patient has entered the clinic with shallow respirations up to 37 breaths per minute, dry
hacking cough, and elevated heart rate. What are the following cues the nurse spots that are
aligned with left ventricular heart failure?
A. Elevated Heart Rate
B. Dry hacking cough
C. Shallow respirations
D. Food poisoning
E. Edema - Answers A. Elevated Heart Rate
B. Dry hacking cough
C. Shallow respirations
A patient is experiencing respiratory distress. Which action should the nurse take first?
A. Assess airway patency by looking for signs of obstruction
B. Ask about any history of breathing problems or lung conditions
C. Check vital signs including respiratory rate and oxygen saturation
D. Evaluate the patient's ability to speak in full sentences - Answers A. Assess airway patency by
looking for signs of obstruction
A nurse is caring for a 72-year-old patient with COPD who suddenly becomes short of breath, is
using accessory muscles to breathe, and has an oxygen saturation of 88% on room air. The
nurse administers a nebulized bronchodilator and applies oxygen at 2 L/min via nasal cannula.
Which information should the nurse include when stating the "Background" element for SBAR
communication?
A) Current vital signs
B) Chief complaint and medical history
C) Code status and allergies
D) Plan of care and proposed interventions - Answers B) Chief complaint and medical history
A nurse is calling the provider about a postoperative patient who has a blood pressure of 88/50
mmHg, heart rate of 114 bpm, and is reporting dizziness when standing. After presenting the
situation, background, and assessment, which statement best reflects an appropriate
Recommendation?
A. "I just wanted to inform you of the patient's vital signs."
B. "The patient's blood pressure is low, and I'm not sure what to do."
C. "Can we consider holding the patient's antihypertensive medication and administering IV
fluids?"
D. "The patient's condition has changed and seems unstable." - Answers C. "Can we consider
holding the patient's antihypertensive medication and administering IV fluids?"
A nurse is caring for a patient with a highly contagious respiratory virus, which nursing practice
will help prevent the spread of the virus through the portal of exit?
A. Discarding all used tissues into the trash can
B. Allowing supervised ambulation in the hallway
C. Keeping the patient's bathroom door closed
D. Having the patient cover their mouth while coughing - Answers D. Having the patient cover
their mouth while coughing
A nurse is caring for a client with a wound infected with MRSA. Which of the following infection
control precautions should the nurse implement?
,A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only - Answers C. Contact precautions
A nurse is preparing to insert a peripheral IV catheter for a patient in the emergency department.
Which aseptic technique should the nurse use?
A) Medical asepsis
B) Surgical asepsis
C) Sterilization of all equipment and the patient's entire arm
D) No aseptic technique is needed - Answers A) Medical asepsis
During inspection of a patient's lower extremities, the nurse notes several findings. Which of the
following requires priority intervention?
A. Scattered bruising on the shins
B. Slight bilateral ankle edema in the evening
C. Pale, cool skin with a shiny appearance and loss of hair on the legs
D. A 1+ dorsalis pedis pulse bilaterally - Answers C. Pale, cool skin with a shiny appearance and
loss of hair on the legs
A nurse is assessing a client admitted with abdominal pain. Which of the following client
statements should the nurse document as subjective data?
A. "The client's abdomen is distended."
B. "The client winces during palpation of the right lower quadrant."
C. "Client states, 'My stomach hurts really bad and I feel nauseous.'"
D. "The client's temperature is 101.2°F (38.4°C)." - Answers C. "Client states, 'My stomach hurts
really bad and I feel nauseous.'"
, A nurse is preparing to administer an antihypertensive medication to a patient. Which of the
following vital signs should the nurse assess before giving the medication?
A) Body temperature
B) Respiratory rate
C) Blood pressure
D) Heart rate - Answers C) Blood pressure
A patient has entered the clinic with shallow respirations up to 37 breaths per minute, dry
hacking cough, and elevated heart rate. What are the following cues the nurse spots that are
aligned with left ventricular heart failure?
A. Elevated Heart Rate
B. Dry hacking cough
C. Shallow respirations
D. Food poisoning
E. Edema - Answers A. Elevated Heart Rate
B. Dry hacking cough
C. Shallow respirations
A patient is experiencing respiratory distress. Which action should the nurse take first?
A. Assess airway patency by looking for signs of obstruction
B. Ask about any history of breathing problems or lung conditions
C. Check vital signs including respiratory rate and oxygen saturation
D. Evaluate the patient's ability to speak in full sentences - Answers A. Assess airway patency by
looking for signs of obstruction
A nurse is caring for a 72-year-old patient with COPD who suddenly becomes short of breath, is
using accessory muscles to breathe, and has an oxygen saturation of 88% on room air. The
nurse administers a nebulized bronchodilator and applies oxygen at 2 L/min via nasal cannula.
