NUR 211 Final Exam – Comprehensive Questions and
Answers with Detailed Rationales
1. A nurse is assessing a client who reports sudden shortness of breath
and chest discomfort. Which assessment finding requires the nurse's
immediate attention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 88%
C. Temperature of 37.1°C
D. Blood pressure of 124/78 mmHg
Answer: B. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and
requires prompt assessment and intervention. The other findings are
within expected adult ranges.
2. Which nursing action best demonstrates the principle of standard
precautions?
A. Wearing gloves only when caring for clients with known infections
B. Treating all blood and body fluids as potentially infectious
C. Placing every client in airborne isolation
D. Using an N95 respirator for every client encounter
Answer: B. Treating all blood and body fluids as potentially infectious
Rationale: Standard precautions require healthcare workers to assume
that blood and certain body fluids may contain infectious organisms
regardless of the client's diagnosis.
,3. A client is receiving oxygen through a nasal cannula. Which nursing
intervention is appropriate?
A. Apply petroleum jelly inside the nares
B. Assess the client's skin around the ears and nose
C. Increase the oxygen flow rate without an order
D. Remove the oxygen during sleep
Answer: B. Assess the client's skin around the ears and nose
Rationale: Nasal cannula tubing can cause pressure-related irritation.
The nurse should regularly assess the nares, cheeks, and ears and
provide appropriate skin protection.
4. Which finding most strongly suggests that a client is experiencing
dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Concentrated urine
D. Peripheral edema
Answer: C. Concentrated urine
Rationale: Dehydration commonly causes decreased urine output and
concentrated urine because the kidneys conserve water.
5. A nurse is preparing to administer medication. Which action is most
important before administration?
A. Ask another client whether the medication is familiar
B. Verify the medication against the medication administration record
,C. Leave the medication at the bedside
D. Document administration before giving the medication
Answer: B. Verify the medication against the medication
administration record
Rationale: Medication verification is essential for preventing
medication errors. Documentation should occur after administration,
not before.
6. Which client should the nurse assess first?
A. A client requesting assistance with bathing
B. A client reporting new-onset difficulty breathing
C. A client asking when lunch will arrive
D. A client requesting a television remote
Answer: B. A client reporting new-onset difficulty breathing
Rationale: Airway and breathing problems take priority under the ABC
framework. New respiratory difficulty can indicate an acute and
potentially life-threatening problem.
7. Which intervention is most appropriate for preventing pressure
injuries in an immobile client?
A. Massage reddened bony prominences
B. Reposition the client regularly
C. Keep the client's skin continuously moist
D. Restrict protein intake
Answer: B. Reposition the client regularly
, Rationale: Regular repositioning reduces prolonged pressure over bony
prominences. Massage over reddened areas can cause tissue damage.
8. Which assessment finding is most concerning in a client receiving
opioid analgesia?
A. Pain rating of 3/10
B. Respiratory rate of 8/min
C. Mild nausea
D. Drowsiness after administration
Answer: B. Respiratory rate of 8/min
Rationale: Opioids can suppress the respiratory center. A respiratory
rate of 8/min is concerning for opioid-induced respiratory depression
and requires immediate assessment and intervention.
9. Which statement by a client demonstrates correct understanding of
fall prevention?
A. “I should get out of bed quickly when I need to use the bathroom.”
B. “I should keep the call light within reach.”
C. “I should wear loose socks when walking.”
D. “I should turn off the room light before walking.”
Answer: B. “I should keep the call light within reach.”
Rationale: Keeping the call light accessible allows the client to request
assistance before attempting to ambulate.
10. A client has a potassium level of 2.8 mEq/L. Which assessment
finding would the nurse anticipate?
Answers with Detailed Rationales
1. A nurse is assessing a client who reports sudden shortness of breath
and chest discomfort. Which assessment finding requires the nurse's
immediate attention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 88%
C. Temperature of 37.1°C
D. Blood pressure of 124/78 mmHg
Answer: B. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and
requires prompt assessment and intervention. The other findings are
within expected adult ranges.
2. Which nursing action best demonstrates the principle of standard
precautions?
A. Wearing gloves only when caring for clients with known infections
B. Treating all blood and body fluids as potentially infectious
C. Placing every client in airborne isolation
D. Using an N95 respirator for every client encounter
Answer: B. Treating all blood and body fluids as potentially infectious
Rationale: Standard precautions require healthcare workers to assume
that blood and certain body fluids may contain infectious organisms
regardless of the client's diagnosis.
,3. A client is receiving oxygen through a nasal cannula. Which nursing
intervention is appropriate?
A. Apply petroleum jelly inside the nares
B. Assess the client's skin around the ears and nose
C. Increase the oxygen flow rate without an order
D. Remove the oxygen during sleep
Answer: B. Assess the client's skin around the ears and nose
Rationale: Nasal cannula tubing can cause pressure-related irritation.
The nurse should regularly assess the nares, cheeks, and ears and
provide appropriate skin protection.
4. Which finding most strongly suggests that a client is experiencing
dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Concentrated urine
D. Peripheral edema
Answer: C. Concentrated urine
Rationale: Dehydration commonly causes decreased urine output and
concentrated urine because the kidneys conserve water.
5. A nurse is preparing to administer medication. Which action is most
important before administration?
A. Ask another client whether the medication is familiar
B. Verify the medication against the medication administration record
,C. Leave the medication at the bedside
D. Document administration before giving the medication
Answer: B. Verify the medication against the medication
administration record
Rationale: Medication verification is essential for preventing
medication errors. Documentation should occur after administration,
not before.
6. Which client should the nurse assess first?
A. A client requesting assistance with bathing
B. A client reporting new-onset difficulty breathing
C. A client asking when lunch will arrive
D. A client requesting a television remote
Answer: B. A client reporting new-onset difficulty breathing
Rationale: Airway and breathing problems take priority under the ABC
framework. New respiratory difficulty can indicate an acute and
potentially life-threatening problem.
7. Which intervention is most appropriate for preventing pressure
injuries in an immobile client?
A. Massage reddened bony prominences
B. Reposition the client regularly
C. Keep the client's skin continuously moist
D. Restrict protein intake
Answer: B. Reposition the client regularly
, Rationale: Regular repositioning reduces prolonged pressure over bony
prominences. Massage over reddened areas can cause tissue damage.
8. Which assessment finding is most concerning in a client receiving
opioid analgesia?
A. Pain rating of 3/10
B. Respiratory rate of 8/min
C. Mild nausea
D. Drowsiness after administration
Answer: B. Respiratory rate of 8/min
Rationale: Opioids can suppress the respiratory center. A respiratory
rate of 8/min is concerning for opioid-induced respiratory depression
and requires immediate assessment and intervention.
9. Which statement by a client demonstrates correct understanding of
fall prevention?
A. “I should get out of bed quickly when I need to use the bathroom.”
B. “I should keep the call light within reach.”
C. “I should wear loose socks when walking.”
D. “I should turn off the room light before walking.”
Answer: B. “I should keep the call light within reach.”
Rationale: Keeping the call light accessible allows the client to request
assistance before attempting to ambulate.
10. A client has a potassium level of 2.8 mEq/L. Which assessment
finding would the nurse anticipate?
