HUMAN CASE STUDY ACTUAL EXAM PAPER
2026 QUESTIONS WITH ANSWERS GRADED
A+
▶ The nurse accidentally administers 10 mg of morphine intravenously to a client who
had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What
action must the nurse be prepared to take?
A) Assist with intubation.
B) Monitor pain level.
C) Administer oxygen.
D) Administer naloxone (Narcan). Answer: D
A combined dose of 15 mg of morphine may cause severe respiratory depression in
some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the
first intervention to reverse respiratory depression due to a morphine overdose. Then
administration of oxygen may be needed if the client's oxygen saturation decreases.
Intubation may occur if the client does not respond to the Narcan, and respiratory
depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level
of the client needs to be monitored because Narcan can promote withdrawal symptoms.
▶ Which action does the nurse teach a client to reduce the risk for dehydration?
A) Avoiding the use of glycerin suppositories to manage constipation
B) Maintaining a daily oral intake approximately equal to daily fluid loss
C) Restricting sodium intake to no greater than 4 g/day
D) Maintaining an oral intake of at least 1500 mL/day Answer: B
Although a fixed oral intake of 1500 mL daily is good, the key to prevention of
dehydration is to match all fluid losses with the same volume for fluid intake. This is
especially true in warm or dry environments, or when conditions result in greater than
usual fluid loss through perspiration or ventilation.
▶ A client is taking furosemide (Lasix) and becomes confused. Which potassium level
does the nurse correlate with this condition?
A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L Answer: A
Hypokalemia decreases cerebral function and is manifested by lethargy, confusion,
inability to perform problem-solving tasks, disorientation, and coma. Normal potassium
,levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to
neurologic manifestations.
▶ The most appropriate measure for a nurse to use in assessing core body temperature
when there are suspected problems with thermoregulation is a(n)
A) rectal thermometer.
B) tympanic membrane sensor.
C) temporal thermometer scan.
D) oral thermometer. Answer: A
The most reliable means available for assessing core temperature is a rectal
temperature, which is considered the standard of practice. An oral temperature is a
common measure but not the most reliable. A temporal thermometer scan has some
limitations and is not the standard. The tympanic membrane sensor could be used as a
second source for temperature assessment.
▶ A client presents to the emergency department after prolonged exposure to the cold.
The client is shivering, has slurred speech, and is slow to respond to questions. Which
intervention will the nurse prepare for this client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids Answer: B
Mild hypothermia is manifested by shivering, slurred speech, poor muscular
coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry
clothing and warm blankets. Rewarming should occur slowly by removing wet clothing
and providing dry warm blankets first. Other treatments are secondary and should be
used to treat moderate to severe hypothermia.
▶ The Joint Commission focuses on safety in health care. Which action by the nurse
reflects The Joint Commission's main objective?
A) Performing range-of-motion exercises on the client three times each day
B) Assessing the client's respirations when administering opioids
C) Delegating to the nursing assistant to give the client a complete bath daily
D) Ensuring that the client is eating 100% of the meals served to him or her Answer: B
It is important for the nurse to assess respirations of the client when administering
opioids because of the possibility of respiratory depression. The other interventions may
or may not be necessary in the care of the client and do not focus on safety.
▶ What is a priority nursing intervention to prevent falls for an older adult client with
multiple chronic diseases?
,A) Requesting that a family member remain with the client to assist in ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement without assistance
D) Providing assistance to the client in getting out of the bed or chair Answer: D
Advanced age and multiple illnesses, particularly those that result in alterations in
sensation, such as diabetes, predispose this client to falls. The nurse should provide
assistance to the client with transfer and ambulation to prevent falls. The client should
not be restrained or maintained on bedrest without adequate indication. Although family
members are encouraged to visit, their presence around the clock is not necessary at
this point.
▶ The nurse is caring for four clients. Which client assessment is the most indicative of
having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision Answer: B
At times clients are unable to verbalize that they are in pain but there are indicators that
the client may have acute pain such as increased heart rate, increased blood pressure,
increased respirations, sweating, restlessness, and overall distress. All the other
distractors could indicate clients who have the potential for being in pain, but
restlessness with tachycardia is the most indicative.
▶ The Institute for Healthcare Improvement (IHI) identified interventions to save client
lives. Which actions are within the scope of nursing practice to improve quality of care?
A) Prescribe aspirin for a client who presents with an acute myocardial infarction
B) Insert a central line to give intravenous fluid to a dehydrated client.
C) Use sterile technique when changing dressings on a new surgical site.
D) Intubate a client whose oxygen saturation is 92%. Answer: C
The only intervention identified within the scope of nursing practice is to use sterile
technique. Central line insertion, intubation, and prescription are functions of the
physician.
▶ Which is most indicative of pain in an older client who is confused? (Select all that
apply).
A) Screaming
B) Decreased blood pressure
C) Crying
D) Decreased respirations
E) Facial grimace
, F) Restlessness Answer: A,C,E,F
No one scale has been found to be the best tool to use in pain assessment for adults
with cognitive impairment. Facial expression, motor behavior, mood, socialization, and
vocalization are common indicators of pain in cognitively impaired adults. In acute pain,
nonverbal indicators of pain could include increased blood pressure and respirations.
▶ The nursery nurse identifies a newborn at significant risk for hypothermic alteration in
thermoregulation because the patient is:
A) large for gestational age.
B) well nourished.
C) born at term.
D) low birth weight. Answer: D
Low birth weight and poorly nourished infants (particularly premature infants) and
children are at greatest risk for hypothermia. A large for gestational age infant would not
be malnourished. An infant born at term is not considered at significant risk. A well
nourished infant is not at significant risk.
▶ The nurse is assessing a patient's functional ability. Which activities most closely
match the definition of functional ability?
A) Healthy individual, college educated, travels frequently, can balance a checkbook
B) Healthy individual, works out, reads well, cooks and cleans house
C) Healthy individual, volunteers at church, works part time, takes care of family and
house
D) Healthy individual, works outside the home, uses a cane, well groomed Answer: C
Functional ability refers to the individual's ability to perform the normal daily activities
required to meet basic needs; fulfill usual roles in the family, workplace, and community;
and maintain health and well-being. The other options are good; however, each option
has advanced or independent activities in the context of the option.
▶ Which action demonstrates that the nurse understands the purpose of the Rapid
Response Team?
A) Documenting all changes observed in the client and maintaining a postoperative flow
sheet
B) Monitoring the client for changes in postoperative status such as wound infection
C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm
Hg systolic
D) Notifying the physician of the client's increase in restlessness after medication
change Answer: C
2026 QUESTIONS WITH ANSWERS GRADED
A+
▶ The nurse accidentally administers 10 mg of morphine intravenously to a client who
had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What
action must the nurse be prepared to take?
A) Assist with intubation.
B) Monitor pain level.
C) Administer oxygen.
D) Administer naloxone (Narcan). Answer: D
A combined dose of 15 mg of morphine may cause severe respiratory depression in
some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the
first intervention to reverse respiratory depression due to a morphine overdose. Then
administration of oxygen may be needed if the client's oxygen saturation decreases.
Intubation may occur if the client does not respond to the Narcan, and respiratory
depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level
of the client needs to be monitored because Narcan can promote withdrawal symptoms.
▶ Which action does the nurse teach a client to reduce the risk for dehydration?
A) Avoiding the use of glycerin suppositories to manage constipation
B) Maintaining a daily oral intake approximately equal to daily fluid loss
C) Restricting sodium intake to no greater than 4 g/day
D) Maintaining an oral intake of at least 1500 mL/day Answer: B
Although a fixed oral intake of 1500 mL daily is good, the key to prevention of
dehydration is to match all fluid losses with the same volume for fluid intake. This is
especially true in warm or dry environments, or when conditions result in greater than
usual fluid loss through perspiration or ventilation.
▶ A client is taking furosemide (Lasix) and becomes confused. Which potassium level
does the nurse correlate with this condition?
A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L Answer: A
Hypokalemia decreases cerebral function and is manifested by lethargy, confusion,
inability to perform problem-solving tasks, disorientation, and coma. Normal potassium
,levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to
neurologic manifestations.
▶ The most appropriate measure for a nurse to use in assessing core body temperature
when there are suspected problems with thermoregulation is a(n)
A) rectal thermometer.
B) tympanic membrane sensor.
C) temporal thermometer scan.
D) oral thermometer. Answer: A
The most reliable means available for assessing core temperature is a rectal
temperature, which is considered the standard of practice. An oral temperature is a
common measure but not the most reliable. A temporal thermometer scan has some
limitations and is not the standard. The tympanic membrane sensor could be used as a
second source for temperature assessment.
▶ A client presents to the emergency department after prolonged exposure to the cold.
The client is shivering, has slurred speech, and is slow to respond to questions. Which
intervention will the nurse prepare for this client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids Answer: B
Mild hypothermia is manifested by shivering, slurred speech, poor muscular
coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry
clothing and warm blankets. Rewarming should occur slowly by removing wet clothing
and providing dry warm blankets first. Other treatments are secondary and should be
used to treat moderate to severe hypothermia.
▶ The Joint Commission focuses on safety in health care. Which action by the nurse
reflects The Joint Commission's main objective?
A) Performing range-of-motion exercises on the client three times each day
B) Assessing the client's respirations when administering opioids
C) Delegating to the nursing assistant to give the client a complete bath daily
D) Ensuring that the client is eating 100% of the meals served to him or her Answer: B
It is important for the nurse to assess respirations of the client when administering
opioids because of the possibility of respiratory depression. The other interventions may
or may not be necessary in the care of the client and do not focus on safety.
▶ What is a priority nursing intervention to prevent falls for an older adult client with
multiple chronic diseases?
,A) Requesting that a family member remain with the client to assist in ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement without assistance
D) Providing assistance to the client in getting out of the bed or chair Answer: D
Advanced age and multiple illnesses, particularly those that result in alterations in
sensation, such as diabetes, predispose this client to falls. The nurse should provide
assistance to the client with transfer and ambulation to prevent falls. The client should
not be restrained or maintained on bedrest without adequate indication. Although family
members are encouraged to visit, their presence around the clock is not necessary at
this point.
▶ The nurse is caring for four clients. Which client assessment is the most indicative of
having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision Answer: B
At times clients are unable to verbalize that they are in pain but there are indicators that
the client may have acute pain such as increased heart rate, increased blood pressure,
increased respirations, sweating, restlessness, and overall distress. All the other
distractors could indicate clients who have the potential for being in pain, but
restlessness with tachycardia is the most indicative.
▶ The Institute for Healthcare Improvement (IHI) identified interventions to save client
lives. Which actions are within the scope of nursing practice to improve quality of care?
A) Prescribe aspirin for a client who presents with an acute myocardial infarction
B) Insert a central line to give intravenous fluid to a dehydrated client.
C) Use sterile technique when changing dressings on a new surgical site.
D) Intubate a client whose oxygen saturation is 92%. Answer: C
The only intervention identified within the scope of nursing practice is to use sterile
technique. Central line insertion, intubation, and prescription are functions of the
physician.
▶ Which is most indicative of pain in an older client who is confused? (Select all that
apply).
A) Screaming
B) Decreased blood pressure
C) Crying
D) Decreased respirations
E) Facial grimace
, F) Restlessness Answer: A,C,E,F
No one scale has been found to be the best tool to use in pain assessment for adults
with cognitive impairment. Facial expression, motor behavior, mood, socialization, and
vocalization are common indicators of pain in cognitively impaired adults. In acute pain,
nonverbal indicators of pain could include increased blood pressure and respirations.
▶ The nursery nurse identifies a newborn at significant risk for hypothermic alteration in
thermoregulation because the patient is:
A) large for gestational age.
B) well nourished.
C) born at term.
D) low birth weight. Answer: D
Low birth weight and poorly nourished infants (particularly premature infants) and
children are at greatest risk for hypothermia. A large for gestational age infant would not
be malnourished. An infant born at term is not considered at significant risk. A well
nourished infant is not at significant risk.
▶ The nurse is assessing a patient's functional ability. Which activities most closely
match the definition of functional ability?
A) Healthy individual, college educated, travels frequently, can balance a checkbook
B) Healthy individual, works out, reads well, cooks and cleans house
C) Healthy individual, volunteers at church, works part time, takes care of family and
house
D) Healthy individual, works outside the home, uses a cane, well groomed Answer: C
Functional ability refers to the individual's ability to perform the normal daily activities
required to meet basic needs; fulfill usual roles in the family, workplace, and community;
and maintain health and well-being. The other options are good; however, each option
has advanced or independent activities in the context of the option.
▶ Which action demonstrates that the nurse understands the purpose of the Rapid
Response Team?
A) Documenting all changes observed in the client and maintaining a postoperative flow
sheet
B) Monitoring the client for changes in postoperative status such as wound infection
C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm
Hg systolic
D) Notifying the physician of the client's increase in restlessness after medication
change Answer: C
