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Question 1
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD).
Which finding requires immediate intervention?
A. Barrel-shaped chest
B. Productive cough
C. Oxygen saturation of 88%
D. Increasing confusion and restlessness
Correct Answer: D
Rationale: Increasing confusion and restlessness indicate hypoxia and possible
carbon dioxide retention, which is an acute and life-threatening change requiring
immediate intervention.
Question 2
A nurse is preparing to administer digoxin to a client with heart failure. Which
assessment finding should cause the nurse to withhold the medication?
A. Heart rate of 58 beats/min
B. Blood pressure of 140/88 mm Hg
C. Potassium level of 4.0 mEq/L
D. Respiratory rate of 20/min
Correct Answer: A
,Rationale: Digoxin should be withheld if the apical pulse is below 60 beats/min
due to the risk of bradycardia and toxicity.
Question 3
A client with diabetes mellitus reports feeling shaky, diaphoretic, and dizzy. Which
action should the nurse take first?
A. Administer insulin
B. Check the client’s blood glucose level
C. Encourage deep breathing
D. Document the findings
Correct Answer: B
Rationale: Symptoms suggest hypoglycemia. The nurse must first verify blood
glucose to guide immediate treatment.
Question 4
A nurse is teaching a client about warfarin therapy. Which statement by the client
indicates understanding?
A. “I will increase my intake of green leafy vegetables.”
B. “I should take aspirin for pain.”
C. “I will have my INR checked regularly.”
D. “I can stop the medication when I feel better.”
Correct Answer: C
Rationale: Regular INR monitoring is essential to maintain therapeutic
anticoagulation and prevent bleeding or clotting complications.
,Question 5
A nurse is caring for a postoperative client. Which finding is most indicative of a
developing infection?
A. Pain at the incision site
B. Mild swelling
C. Temperature of 38.5°C (101.3°F)
D. Decreased appetite
Correct Answer: C
Rationale: Fever is a systemic sign of infection and is more concerning than
expected postoperative discomfort or swelling.
Question 6
A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task
is appropriate to delegate?
A. Assessing pain level
B. Administering oral medications
C. Measuring intake and output
D. Teaching incentive spirometry
Correct Answer: C
Rationale: Measuring intake and output is within the scope of UAP practice and
does not require nursing judgment.
Question 7
A client receiving IV fluids develops crackles in the lungs and shortness of breath.
Which action should the nurse take first?
A. Document the findings
B. Slow the IV infusion
C. Administer oxygen
D. Notify the provider
, Correct Answer: B
Rationale: The findings suggest fluid overload. Slowing the infusion addresses the
cause immediately and helps prevent worsening pulmonary edema.
Question 8
A nurse is caring for a client with a newly placed colostomy. Which finding
indicates a normal stoma?
A. Pale pink color
B. Bluish discoloration
C. Dry and dark tissue
D. Bright red, moist appearance
Correct Answer: D
Rationale: A healthy stoma should be moist and red, similar in appearance to oral
mucosa.
Question 9
A client with tuberculosis is admitted to the unit. Which type of isolation
precautions are required?
A. Contact
B. Droplet
C. Airborne
D. Protective
Correct Answer: C
Rationale: Tuberculosis is transmitted via airborne particles and requires airborne
precautions, including a negative-pressure room.