Test 1 Materials NURS 5432 Questions With
Complete Solutions
Question 1
A nurse is caring for a patient with acute respiratory distress.
Which assessment finding requires immediate intervention?
A. Respiratory rate of 24/min
B. Oxygen saturation of 84% on room air
C. Heart rate of 102 beats/min
D. Temperature of 99.8°F (37.7°C)
Answer: B
Rationale: An oxygen saturation of 84% indicates severe
hypoxemia requiring immediate oxygen therapy and further
assessment.
• A: Mild tachypnea is concerning but not the priority.
• C: Mild tachycardia commonly accompanies respiratory
distress.
• D: This temperature is not immediately life-threatening.
Question 2
Which laboratory value should the nurse report immediately?
,A. Sodium 138 mEq/L
B. Potassium 6.2 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mg/dL
Answer: B
Rationale: Hyperkalemia can precipitate life-threatening cardiac
dysrhythmias and requires urgent intervention.
Question 3
Which patient should the nurse assess first?
A. Patient with chronic arthritis pain rated 6/10
B. Patient receiving blood transfusion who develops chills
C. Patient awaiting discharge instructions
D. Patient requesting assistance to the bathroom
Answer: B
Rationale: Chills during a blood transfusion may indicate an
acute transfusion reaction requiring immediate cessation of the
transfusion and rapid assessment.
Question 4
A patient suddenly develops facial drooping and slurred speech.
What is the nurse's priority?
A. Obtain blood cultures
B. Activate the stroke protocol
, C. Administer acetaminophen
D. Encourage oral fluids
Answer: B
Rationale: Time-sensitive evaluation is critical because early
treatment can significantly improve outcomes in acute ischemic
stroke.
Question 5
Which finding is most consistent with hypoglycemia?
A. Bradycardia
B. Cool, clammy skin
C. Hypertension
D. Dry mucous membranes
Answer: B
Rationale: Adrenergic stimulation during hypoglycemia
produces diaphoresis, tremors, tachycardia, and clammy skin.
Question 6
Which medication should the nurse question before
administration?
A. Metoprolol for heart rate 48/min
B. Acetaminophen for temperature 101°F
C. Furosemide for pulmonary edema
D. Ceftriaxone for pneumonia
Complete Solutions
Question 1
A nurse is caring for a patient with acute respiratory distress.
Which assessment finding requires immediate intervention?
A. Respiratory rate of 24/min
B. Oxygen saturation of 84% on room air
C. Heart rate of 102 beats/min
D. Temperature of 99.8°F (37.7°C)
Answer: B
Rationale: An oxygen saturation of 84% indicates severe
hypoxemia requiring immediate oxygen therapy and further
assessment.
• A: Mild tachypnea is concerning but not the priority.
• C: Mild tachycardia commonly accompanies respiratory
distress.
• D: This temperature is not immediately life-threatening.
Question 2
Which laboratory value should the nurse report immediately?
,A. Sodium 138 mEq/L
B. Potassium 6.2 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mg/dL
Answer: B
Rationale: Hyperkalemia can precipitate life-threatening cardiac
dysrhythmias and requires urgent intervention.
Question 3
Which patient should the nurse assess first?
A. Patient with chronic arthritis pain rated 6/10
B. Patient receiving blood transfusion who develops chills
C. Patient awaiting discharge instructions
D. Patient requesting assistance to the bathroom
Answer: B
Rationale: Chills during a blood transfusion may indicate an
acute transfusion reaction requiring immediate cessation of the
transfusion and rapid assessment.
Question 4
A patient suddenly develops facial drooping and slurred speech.
What is the nurse's priority?
A. Obtain blood cultures
B. Activate the stroke protocol
, C. Administer acetaminophen
D. Encourage oral fluids
Answer: B
Rationale: Time-sensitive evaluation is critical because early
treatment can significantly improve outcomes in acute ischemic
stroke.
Question 5
Which finding is most consistent with hypoglycemia?
A. Bradycardia
B. Cool, clammy skin
C. Hypertension
D. Dry mucous membranes
Answer: B
Rationale: Adrenergic stimulation during hypoglycemia
produces diaphoresis, tremors, tachycardia, and clammy skin.
Question 6
Which medication should the nurse question before
administration?
A. Metoprolol for heart rate 48/min
B. Acetaminophen for temperature 101°F
C. Furosemide for pulmonary edema
D. Ceftriaxone for pneumonia
