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NUR 254 EXAM 2 | 150 QUESTIONS AND CORRECT ANSWERS (2026–2027 TEST
BANK,100% CORRECT ALREADY GRADED A+
Question 1
A nurse is caring for a client with pneumonia. Which assessment finding requires
immediate intervention?
A. Productive cough with yellow sputum
B. Respiratory rate of 32/min with use of accessory muscles
C. Low-grade fever of 100.4°F (38°C)
D. Oxygen saturation of 94%
Rationale: Severe tachypnea with accessory muscle use indicates impending
respiratory distress and requires urgent intervention.
Question 2
A client with heart failure is prescribed furosemide. Which laboratory value
should the nurse monitor closely?
A. Hemoglobin
B. Creatinine
C. Potassium
D. Glucose
Rationale: Loop diuretics like furosemide can cause hypokalemia, increasing risk
for dysrhythmias.
Question 3
The nurse is reinforcing teaching about nitroglycerin sublingual use. Which
statement indicates correct understanding?
A. “I should swallow the pill immediately.”
B. “If my chest pain is not relieved after one dose, I can repeat it every 5 minutes
up to 3 times.”
C. “I can take as many tablets as I need until the pain is gone.”
D. “I should lie flat after taking the pill.”
Rationale: Sublingual nitroglycerin can be repeated every 5 minutes for up to 3
doses; beyond that, the client should call EMS.
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Question 4
A client receiving heparin therapy has a PTT of 95 seconds (reference: 25–35).
What should the nurse do first?
A. Continue current infusion
B. Stop the infusion and notify the provider
C. Administer vitamin K
D. Document as expected result
Rationale: A prolonged PTT indicates increased bleeding risk; infusion should be
stopped and provider notified.
Question 5
A nurse is assessing a client with COPD. Which finding is expected?
A. Bradycardia
B. Clear lung sounds
C. Barrel chest
D. Pink skin tone
Rationale: COPD causes chronic hyperinflation of the lungs, resulting in a barrel-
shaped chest.
Question 6
The nurse prepares to administer digoxin. Which finding requires the nurse to
hold the dose?
A. Blood pressure 142/80
B. Apical pulse 48/min
C. Respiratory rate 18/min
D. Potassium 4.0 mEq/L
Rationale: Digoxin should be withheld if heart rate is less than 60/min due to risk
of severe bradycardia.
Question 7
A nurse is caring for a client with suspected deep vein thrombosis (DVT). Which
intervention is appropriate?
A. Encourage early ambulation
B. Apply compression stockings
C. Maintain bed rest with leg elevated
D. Massage the affected extremity
Rationale: Ambulation and massage can dislodge the clot. Elevation reduces
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venous stasis.
Question 8
The nurse is teaching about insulin glargine. Which statement is correct?
A. “I should take it with each meal.”
B. “This insulin has no peak and provides 24-hour coverage.”
C. “It is used to treat hypoglycemia.”
D. “I should mix it with regular insulin.”
Rationale: Insulin glargine is a long-acting insulin with no pronounced peak and
should not be mixed.
Question 9
A nurse is caring for a client with chronic kidney disease. Which dietary teaching is
appropriate?
A. Increase potassium intake
B. High protein diet
C. Restrict sodium and phosphorus
D. Increase fluid intake
Rationale: Clients with CKD require restriction of sodium, potassium, and
phosphorus to prevent complications.
Question 10
A nurse notes ST-segment elevation on a client’s ECG. This finding indicates:
A. Atrial fibrillation
B. Myocardial infarction
C. Pulmonary embolism
D. Heart block
Rationale: ST-segment elevation is a hallmark sign of myocardial infarction
(STEMI).
Question 11
The nurse is monitoring a client receiving IV potassium. Which finding requires
immediate intervention?
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A. Mild burning at IV site
B. Urine output 40 mL/hr
C. Cardiac rhythm showing peaked T waves
D. Slight nausea
Rationale: Peaked T waves indicate hyperkalemia, a life-threatening condition
requiring urgent action.
Question 12
A client reports black, tarry stools while taking aspirin daily. The nurse suspects:
A. Constipation
B. Gastrointestinal bleeding
C. Iron deficiency anemia
D. Hemorrhoids
Rationale: Aspirin increases risk of GI bleeding, which presents as melena (black
stools).
Question 13
The nurse is caring for a client with cirrhosis. Which lab finding is expected?
A. Elevated hemoglobin
B. Elevated bilirubin
C. Decreased ammonia
D. Elevated albumin
Rationale: Liver dysfunction leads to increased bilirubin due to impaired
metabolism.
Question 14
A nurse is teaching about warfarin. Which statement indicates a need for further
teaching?
A. “I will use an electric razor when shaving.”
B. “I will have my INR checked regularly.”
C. “I will increase my green leafy vegetables.”
D. “I will report any unusual bleeding.”
Rationale: Green leafy vegetables are high in vitamin K and can decrease
warfarin’s effectiveness.
Question 15
NUR 254 EXAM 2 | 150 QUESTIONS AND CORRECT ANSWERS (2026–2027 TEST
BANK,100% CORRECT ALREADY GRADED A+
Question 1
A nurse is caring for a client with pneumonia. Which assessment finding requires
immediate intervention?
A. Productive cough with yellow sputum
B. Respiratory rate of 32/min with use of accessory muscles
C. Low-grade fever of 100.4°F (38°C)
D. Oxygen saturation of 94%
Rationale: Severe tachypnea with accessory muscle use indicates impending
respiratory distress and requires urgent intervention.
Question 2
A client with heart failure is prescribed furosemide. Which laboratory value
should the nurse monitor closely?
A. Hemoglobin
B. Creatinine
C. Potassium
D. Glucose
Rationale: Loop diuretics like furosemide can cause hypokalemia, increasing risk
for dysrhythmias.
Question 3
The nurse is reinforcing teaching about nitroglycerin sublingual use. Which
statement indicates correct understanding?
A. “I should swallow the pill immediately.”
B. “If my chest pain is not relieved after one dose, I can repeat it every 5 minutes
up to 3 times.”
C. “I can take as many tablets as I need until the pain is gone.”
D. “I should lie flat after taking the pill.”
Rationale: Sublingual nitroglycerin can be repeated every 5 minutes for up to 3
doses; beyond that, the client should call EMS.
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Question 4
A client receiving heparin therapy has a PTT of 95 seconds (reference: 25–35).
What should the nurse do first?
A. Continue current infusion
B. Stop the infusion and notify the provider
C. Administer vitamin K
D. Document as expected result
Rationale: A prolonged PTT indicates increased bleeding risk; infusion should be
stopped and provider notified.
Question 5
A nurse is assessing a client with COPD. Which finding is expected?
A. Bradycardia
B. Clear lung sounds
C. Barrel chest
D. Pink skin tone
Rationale: COPD causes chronic hyperinflation of the lungs, resulting in a barrel-
shaped chest.
Question 6
The nurse prepares to administer digoxin. Which finding requires the nurse to
hold the dose?
A. Blood pressure 142/80
B. Apical pulse 48/min
C. Respiratory rate 18/min
D. Potassium 4.0 mEq/L
Rationale: Digoxin should be withheld if heart rate is less than 60/min due to risk
of severe bradycardia.
Question 7
A nurse is caring for a client with suspected deep vein thrombosis (DVT). Which
intervention is appropriate?
A. Encourage early ambulation
B. Apply compression stockings
C. Maintain bed rest with leg elevated
D. Massage the affected extremity
Rationale: Ambulation and massage can dislodge the clot. Elevation reduces
,3|Page
venous stasis.
Question 8
The nurse is teaching about insulin glargine. Which statement is correct?
A. “I should take it with each meal.”
B. “This insulin has no peak and provides 24-hour coverage.”
C. “It is used to treat hypoglycemia.”
D. “I should mix it with regular insulin.”
Rationale: Insulin glargine is a long-acting insulin with no pronounced peak and
should not be mixed.
Question 9
A nurse is caring for a client with chronic kidney disease. Which dietary teaching is
appropriate?
A. Increase potassium intake
B. High protein diet
C. Restrict sodium and phosphorus
D. Increase fluid intake
Rationale: Clients with CKD require restriction of sodium, potassium, and
phosphorus to prevent complications.
Question 10
A nurse notes ST-segment elevation on a client’s ECG. This finding indicates:
A. Atrial fibrillation
B. Myocardial infarction
C. Pulmonary embolism
D. Heart block
Rationale: ST-segment elevation is a hallmark sign of myocardial infarction
(STEMI).
Question 11
The nurse is monitoring a client receiving IV potassium. Which finding requires
immediate intervention?
, 4|Page
A. Mild burning at IV site
B. Urine output 40 mL/hr
C. Cardiac rhythm showing peaked T waves
D. Slight nausea
Rationale: Peaked T waves indicate hyperkalemia, a life-threatening condition
requiring urgent action.
Question 12
A client reports black, tarry stools while taking aspirin daily. The nurse suspects:
A. Constipation
B. Gastrointestinal bleeding
C. Iron deficiency anemia
D. Hemorrhoids
Rationale: Aspirin increases risk of GI bleeding, which presents as melena (black
stools).
Question 13
The nurse is caring for a client with cirrhosis. Which lab finding is expected?
A. Elevated hemoglobin
B. Elevated bilirubin
C. Decreased ammonia
D. Elevated albumin
Rationale: Liver dysfunction leads to increased bilirubin due to impaired
metabolism.
Question 14
A nurse is teaching about warfarin. Which statement indicates a need for further
teaching?
A. “I will use an electric razor when shaving.”
B. “I will have my INR checked regularly.”
C. “I will increase my green leafy vegetables.”
D. “I will report any unusual bleeding.”
Rationale: Green leafy vegetables are high in vitamin K and can decrease
warfarin’s effectiveness.
Question 15
