REX-PN ACTUAL EXAM | QUESTIONS AND ANSWERS |
VERIFIED ANSWERS PLUS RATIONALES | EXAM
ALREADY GRADED A+ | LATEST EXAM
1. A nurse is caring for a patient with chronic heart failure. Which assessment finding
indicates fluid overload?
A. Dry mucous membranes
B. Jugular vein distension
C. Hypotension
D. Bradycardia
Answer: B. Jugular vein distension – Jugular vein distension is a common sign of fluid overload
in heart failure patients.
2. A patient is receiving IV antibiotics. The nurse notes redness and swelling at the IV site.
What is the priority action?
A. Apply warm compress
B. Stop the infusion and remove IV
C. Notify the physician in 24 hours
D. Document findings only
Answer: B. Stop the infusion and remove IV – Redness and swelling suggest infiltration or
phlebitis, which requires stopping the IV to prevent further tissue damage.
3. A nurse is teaching a patient about using a metered-dose inhaler. Which instruction is
correct?
A. Exhale completely before inhaling the medication
B. Shake the inhaler after each puff
C. Inhale rapidly and deeply, then hold breath for 5 seconds
D. Use only once daily
Answer: A. Exhale completely before inhaling the medication – Exhaling fully ensures optimal
lung expansion and medication delivery.
4. A patient reports chest pain radiating to the left arm. Which action should the nurse take
first?
A. Administer sublingual nitroglycerin
B. Assess vital signs and ECG
C. Place the patient in a supine position
D. Call the family
Answer: B. Assess vital signs and ECG – Initial assessment determines the severity and guides
immediate interventions for potential myocardial infarction.
, 5. Which intervention is most appropriate for a patient with acute confusion?
A. Restrain the patient
B. Provide a quiet environment and reorient frequently
C. Ignore minor safety risks
D. Encourage excessive stimulation
Answer: B. Provide a quiet environment and reorient frequently – Reducing stimuli and frequent
reorientation helps manage delirium safely.
6. A nurse is preparing to administer a subcutaneous injection. What is the correct angle for
insertion?
A. 15°
B. 45°
C. 60°
D. 90°
Answer: B. 45° – Subcutaneous injections are typically given at 45°, depending on patient size,
to reach fatty tissue.
7. Which lab value indicates a patient is at risk for bleeding?
A. Hemoglobin 14 g/dL
B. Platelet count 50,000/mm³
C. WBC 8,000/mm³
D. Sodium 140 mEq/L
Answer: B. Platelet count 50,000/mm³ – A low platelet count increases bleeding risk due to
impaired clot formation.
8. A patient with type 1 diabetes is experiencing hypoglycemia. Which is the priority
action?
A. Give 15 g of fast-acting carbohydrate
B. Administer insulin
C. Encourage exercise
D. Monitor urine output
Answer: A. Give 15 g of fast-acting carbohydrate – Rapid glucose intake is the immediate
treatment for hypoglycemia.
9. Which patient is at highest risk for pressure injuries?
A. Ambulatory adult
B. Bedridden elderly patient
C. Child with asthma
D. Adult with mild arthritis
Answer: B. Bedridden elderly patient – Immobility, age, and decreased tissue perfusion increase
risk for pressure injuries.
, 10. A nurse is monitoring a patient postoperatively. Which finding is most concerning?
A. Mild incisional redness
B. Respiratory rate 32/min
C. Pain rated 5/10
D. Temp 37°C
Answer: B. Respiratory rate 32/min – Tachypnea postoperatively may indicate hypoxia,
infection, or pulmonary complication.
11. Which position is best for a patient with dyspnea?
A. Supine
B. High Fowler’s
C. Prone
D. Trendelenburg
Answer: B. High Fowler’s – Sitting upright facilitates lung expansion and eases breathing.
12. A patient is prescribed warfarin. Which lab test should the nurse monitor?
A. INR
B. Creatinine
C. WBC
D. Blood glucose
Answer: A. INR – INR monitoring ensures therapeutic anticoagulation and reduces bleeding
risk.
13. A nurse is caring for a patient with COPD. Which intervention helps prevent respiratory
infections?
A. Encourage deep breathing and coughing
B. Limit fluid intake
C. Avoid vaccinations
D. Keep patient in bed continuously
Answer: A. Encourage deep breathing and coughing – This helps clear secretions and reduce
infection risk.
14. A patient with a Foley catheter develops cloudy urine. What is the nurse’s best action?
A. Increase fluid intake
B. Notify the physician and send a urine culture
C. Change the catheter every hour
D. Encourage bed rest
Answer: B. Notify the physician and send a urine culture – Cloudy urine may indicate a urinary
tract infection requiring evaluation.
, 15. A nurse is administering a blood transfusion. What is the first action before starting?
A. Warm the blood
B. Verify patient ID and blood type
C. Administer diuretics
D. Position patient in Trendelenburg
Answer: B. Verify patient ID and blood type – Correct identification prevents transfusion
reactions.
16. A patient is prescribed a new antihypertensive. Which statement indicates understanding?
A. “I will stop taking it if I feel dizzy.”
B. “I should take it at the same time every day.”
C. “I can double the dose if I miss one.”
D. “I should avoid water while taking it.”
Answer: B. “I should take it at the same time every day.” – Taking medication consistently
maintains stable blood pressure control.
17. A nurse is teaching a patient about a low-sodium diet. Which food should the patient
avoid?
A. Fresh vegetables
B. Canned soups
C. Brown rice
D. Fresh fruit
Answer: B. Canned soups – Processed foods like canned soups are high in sodium.
18. A patient is receiving a nasogastric tube feeding. Which action is a priority?
A. Check tube placement before each feeding
B. Leave the tube clamped at all times
C. Give feeding rapidly without monitoring
D. Flush with water only once per day
Answer: A. Check tube placement before each feeding – Correct placement prevents aspiration
and other complications.
19. A nurse is caring for a patient with hypokalemia. Which symptom is expected?
A. Muscle weakness
B. Hypertension
C. Bradycardia
D. Polyuria
Answer: A. Muscle weakness – Low potassium levels affect neuromuscular function causing
weakness.
VERIFIED ANSWERS PLUS RATIONALES | EXAM
ALREADY GRADED A+ | LATEST EXAM
1. A nurse is caring for a patient with chronic heart failure. Which assessment finding
indicates fluid overload?
A. Dry mucous membranes
B. Jugular vein distension
C. Hypotension
D. Bradycardia
Answer: B. Jugular vein distension – Jugular vein distension is a common sign of fluid overload
in heart failure patients.
2. A patient is receiving IV antibiotics. The nurse notes redness and swelling at the IV site.
What is the priority action?
A. Apply warm compress
B. Stop the infusion and remove IV
C. Notify the physician in 24 hours
D. Document findings only
Answer: B. Stop the infusion and remove IV – Redness and swelling suggest infiltration or
phlebitis, which requires stopping the IV to prevent further tissue damage.
3. A nurse is teaching a patient about using a metered-dose inhaler. Which instruction is
correct?
A. Exhale completely before inhaling the medication
B. Shake the inhaler after each puff
C. Inhale rapidly and deeply, then hold breath for 5 seconds
D. Use only once daily
Answer: A. Exhale completely before inhaling the medication – Exhaling fully ensures optimal
lung expansion and medication delivery.
4. A patient reports chest pain radiating to the left arm. Which action should the nurse take
first?
A. Administer sublingual nitroglycerin
B. Assess vital signs and ECG
C. Place the patient in a supine position
D. Call the family
Answer: B. Assess vital signs and ECG – Initial assessment determines the severity and guides
immediate interventions for potential myocardial infarction.
, 5. Which intervention is most appropriate for a patient with acute confusion?
A. Restrain the patient
B. Provide a quiet environment and reorient frequently
C. Ignore minor safety risks
D. Encourage excessive stimulation
Answer: B. Provide a quiet environment and reorient frequently – Reducing stimuli and frequent
reorientation helps manage delirium safely.
6. A nurse is preparing to administer a subcutaneous injection. What is the correct angle for
insertion?
A. 15°
B. 45°
C. 60°
D. 90°
Answer: B. 45° – Subcutaneous injections are typically given at 45°, depending on patient size,
to reach fatty tissue.
7. Which lab value indicates a patient is at risk for bleeding?
A. Hemoglobin 14 g/dL
B. Platelet count 50,000/mm³
C. WBC 8,000/mm³
D. Sodium 140 mEq/L
Answer: B. Platelet count 50,000/mm³ – A low platelet count increases bleeding risk due to
impaired clot formation.
8. A patient with type 1 diabetes is experiencing hypoglycemia. Which is the priority
action?
A. Give 15 g of fast-acting carbohydrate
B. Administer insulin
C. Encourage exercise
D. Monitor urine output
Answer: A. Give 15 g of fast-acting carbohydrate – Rapid glucose intake is the immediate
treatment for hypoglycemia.
9. Which patient is at highest risk for pressure injuries?
A. Ambulatory adult
B. Bedridden elderly patient
C. Child with asthma
D. Adult with mild arthritis
Answer: B. Bedridden elderly patient – Immobility, age, and decreased tissue perfusion increase
risk for pressure injuries.
, 10. A nurse is monitoring a patient postoperatively. Which finding is most concerning?
A. Mild incisional redness
B. Respiratory rate 32/min
C. Pain rated 5/10
D. Temp 37°C
Answer: B. Respiratory rate 32/min – Tachypnea postoperatively may indicate hypoxia,
infection, or pulmonary complication.
11. Which position is best for a patient with dyspnea?
A. Supine
B. High Fowler’s
C. Prone
D. Trendelenburg
Answer: B. High Fowler’s – Sitting upright facilitates lung expansion and eases breathing.
12. A patient is prescribed warfarin. Which lab test should the nurse monitor?
A. INR
B. Creatinine
C. WBC
D. Blood glucose
Answer: A. INR – INR monitoring ensures therapeutic anticoagulation and reduces bleeding
risk.
13. A nurse is caring for a patient with COPD. Which intervention helps prevent respiratory
infections?
A. Encourage deep breathing and coughing
B. Limit fluid intake
C. Avoid vaccinations
D. Keep patient in bed continuously
Answer: A. Encourage deep breathing and coughing – This helps clear secretions and reduce
infection risk.
14. A patient with a Foley catheter develops cloudy urine. What is the nurse’s best action?
A. Increase fluid intake
B. Notify the physician and send a urine culture
C. Change the catheter every hour
D. Encourage bed rest
Answer: B. Notify the physician and send a urine culture – Cloudy urine may indicate a urinary
tract infection requiring evaluation.
, 15. A nurse is administering a blood transfusion. What is the first action before starting?
A. Warm the blood
B. Verify patient ID and blood type
C. Administer diuretics
D. Position patient in Trendelenburg
Answer: B. Verify patient ID and blood type – Correct identification prevents transfusion
reactions.
16. A patient is prescribed a new antihypertensive. Which statement indicates understanding?
A. “I will stop taking it if I feel dizzy.”
B. “I should take it at the same time every day.”
C. “I can double the dose if I miss one.”
D. “I should avoid water while taking it.”
Answer: B. “I should take it at the same time every day.” – Taking medication consistently
maintains stable blood pressure control.
17. A nurse is teaching a patient about a low-sodium diet. Which food should the patient
avoid?
A. Fresh vegetables
B. Canned soups
C. Brown rice
D. Fresh fruit
Answer: B. Canned soups – Processed foods like canned soups are high in sodium.
18. A patient is receiving a nasogastric tube feeding. Which action is a priority?
A. Check tube placement before each feeding
B. Leave the tube clamped at all times
C. Give feeding rapidly without monitoring
D. Flush with water only once per day
Answer: A. Check tube placement before each feeding – Correct placement prevents aspiration
and other complications.
19. A nurse is caring for a patient with hypokalemia. Which symptom is expected?
A. Muscle weakness
B. Hypertension
C. Bradycardia
D. Polyuria
Answer: A. Muscle weakness – Low potassium levels affect neuromuscular function causing
weakness.
