NUR 254 Exam 4|Questions and Answers
| 2025 Update | 100% Correct-Galen
College of Nursing.
Question 1
The nurse is caring for a client with a history of chronic obstructive pulmonary
disease (COPD) who is experiencing shortness of breath and increased sputum
production.
Which of the following actions should the nurse take first?
a. Administer bronchodilators as prescribed.
b. Notify the healthcare provider of the client’s condition.
c. Assess the client’s respiratory rate and oxygen saturation.
✅ d. Encourage the client to cough and deep breathe.
Rationale:
Encouraging the client to cough and deep breathe helps to clear the airway, which
can assist in reducing sputum accumulation. It’s important to assess respiratory
status before administering medications to determine the urgency of care.
Question 2
The nurse is caring for an infant who is diagnosed with dehydration.
Which of the following signs should the nurse recognize as indicating severe
dehydration in the infant?
a. Dry mouth and tongue
✅ b. Sunken fontanels and lethargy
c. Increased urination
d. Normal skin turgor
Rationale:
Severe dehydration in an infant presents with sunken fontanels, lethargy, and
,decreased skin turgor. A dry mouth is a sign of moderate dehydration. Increased
urination is typically not seen in dehydration.
Question 3
The nurse is caring for a client with heart failure who is receiving intravenous (IV)
diuretics.
Which of the following laboratory results should the nurse monitor closely?
a. Hemoglobin and hematocrit levels
b. Liver function tests
✅ c. Potassium and sodium levels
d. Blood urea nitrogen (BUN) and creatinine levels
Rationale:
Diuretics can lead to electrolyte imbalances, particularly low potassium
(hypokalemia) and sodium (hyponatremia). Monitoring potassium and sodium
levels is essential to prevent complications like arrhythmias.
Question 4
The nurse is preparing to administer a medication that requires a double-check for
safety.
Which of the following actions should the nurse take to ensure the medication
is administered safely?
a. Ask a colleague to verify the medication and dose.
b. Check the client’s identification number on the wristband.
✅ c. Have another nurse verify the medication, dose, and client.
d. Review the client’s medical history for allergies.
Rationale:
A double-check involves verifying the medication, dose, and client with another
nurse to ensure safety. While it’s important to check the client’s ID and medical
history, the double-check procedure is the most crucial.
, Question 5
The nurse is caring for a client with type 1 diabetes who is experiencing
hypoglycemia.
Which of the following actions should the nurse take first?
a. Administer insulin as prescribed.
✅ b. Provide the client with a source of fast-acting carbohydrate.
c. Notify the healthcare provider of the client’s condition.
d. Monitor the client’s blood glucose level every 30 minutes.
Rationale:
The priority action in hypoglycemia is to provide a fast-acting carbohydrate (e.g.,
glucose tablets or juice) to raise the client’s blood glucose level quickly.
Administering insulin is contraindicated during hypoglycemia.
Question 6
The nurse is caring for a client who is post-operative following abdominal surgery.
Which of the following actions should the nurse take to reduce the risk of deep
vein thrombosis (DVT) in this client?
a. Elevate the client’s legs above the level of the heart.
b. Encourage the client to ambulate frequently.
✅ c. Apply compression stockings as prescribed.
d. Restrict the client’s fluid intake to prevent edema.
Rationale:
Compression stockings help improve circulation and reduce the risk of DVT.
Encouraging ambulation is also important, but compression stockings provide an
additional protective measure. Elevating legs and restricting fluid intake are not
effective interventions for DVT prevention.
Question 7
| 2025 Update | 100% Correct-Galen
College of Nursing.
Question 1
The nurse is caring for a client with a history of chronic obstructive pulmonary
disease (COPD) who is experiencing shortness of breath and increased sputum
production.
Which of the following actions should the nurse take first?
a. Administer bronchodilators as prescribed.
b. Notify the healthcare provider of the client’s condition.
c. Assess the client’s respiratory rate and oxygen saturation.
✅ d. Encourage the client to cough and deep breathe.
Rationale:
Encouraging the client to cough and deep breathe helps to clear the airway, which
can assist in reducing sputum accumulation. It’s important to assess respiratory
status before administering medications to determine the urgency of care.
Question 2
The nurse is caring for an infant who is diagnosed with dehydration.
Which of the following signs should the nurse recognize as indicating severe
dehydration in the infant?
a. Dry mouth and tongue
✅ b. Sunken fontanels and lethargy
c. Increased urination
d. Normal skin turgor
Rationale:
Severe dehydration in an infant presents with sunken fontanels, lethargy, and
,decreased skin turgor. A dry mouth is a sign of moderate dehydration. Increased
urination is typically not seen in dehydration.
Question 3
The nurse is caring for a client with heart failure who is receiving intravenous (IV)
diuretics.
Which of the following laboratory results should the nurse monitor closely?
a. Hemoglobin and hematocrit levels
b. Liver function tests
✅ c. Potassium and sodium levels
d. Blood urea nitrogen (BUN) and creatinine levels
Rationale:
Diuretics can lead to electrolyte imbalances, particularly low potassium
(hypokalemia) and sodium (hyponatremia). Monitoring potassium and sodium
levels is essential to prevent complications like arrhythmias.
Question 4
The nurse is preparing to administer a medication that requires a double-check for
safety.
Which of the following actions should the nurse take to ensure the medication
is administered safely?
a. Ask a colleague to verify the medication and dose.
b. Check the client’s identification number on the wristband.
✅ c. Have another nurse verify the medication, dose, and client.
d. Review the client’s medical history for allergies.
Rationale:
A double-check involves verifying the medication, dose, and client with another
nurse to ensure safety. While it’s important to check the client’s ID and medical
history, the double-check procedure is the most crucial.
, Question 5
The nurse is caring for a client with type 1 diabetes who is experiencing
hypoglycemia.
Which of the following actions should the nurse take first?
a. Administer insulin as prescribed.
✅ b. Provide the client with a source of fast-acting carbohydrate.
c. Notify the healthcare provider of the client’s condition.
d. Monitor the client’s blood glucose level every 30 minutes.
Rationale:
The priority action in hypoglycemia is to provide a fast-acting carbohydrate (e.g.,
glucose tablets or juice) to raise the client’s blood glucose level quickly.
Administering insulin is contraindicated during hypoglycemia.
Question 6
The nurse is caring for a client who is post-operative following abdominal surgery.
Which of the following actions should the nurse take to reduce the risk of deep
vein thrombosis (DVT) in this client?
a. Elevate the client’s legs above the level of the heart.
b. Encourage the client to ambulate frequently.
✅ c. Apply compression stockings as prescribed.
d. Restrict the client’s fluid intake to prevent edema.
Rationale:
Compression stockings help improve circulation and reduce the risk of DVT.
Encouraging ambulation is also important, but compression stockings provide an
additional protective measure. Elevating legs and restricting fluid intake are not
effective interventions for DVT prevention.
Question 7
