,**1. A patient with heart failure presents with crackles in the lung bases, jugular
vein distention, and 3+ pitting edema in the lower extremities. Which nursing
diagnosis is the priority?**
- A) Impaired Gas Exchange
- **B) Excess Fluid Volume**
- *Rationale: The patient’s crackles, JVD, and edema indicate fluid overload.
Excess Fluid Volume is the priority because it directly contributes to the other
problems like impaired gas exchange.*
**2. A nurse is caring for a client with acute decompensated heart failure
(ADHF) receiving furosemide IV. Which assessment finding requires
immediate action?**
- A) Weight loss of 2 kg in 24 hours
- **B) Serum potassium of 3.0 mEq/L**
- *Rationale: Furosemide causes hypokalemia, which increases the risk of
digoxin toxicity and lethal dysrhythmias. Potassium level of 3.0 is critically low
and needs replacement.*
**3. Which medication is most commonly used as first-line therapy for a patient
with stable angina?**
- **A) Nitroglycerin**
- B) Metoprolol
- C) Amlodipine
- D) Aspirin
,- *Rationale: Nitroglycerin is the first-line agent for acute relief of stable
angina because it vasodilates coronary arteries and reduces preload.*
**4. A patient with chronic obstructive pulmonary disease (COPD) has an
SpO2 of 88%. The nurse should first:**
- A) Apply a non-rebreather mask at 15 L/min
- **B) Administer oxygen via nasal cannula at 2 L/min**
- *Rationale: COPD patients rely on hypoxic drive; high oxygen can cause
CO2 retention and respiratory failure. Start low (2 L/min) and titrate to SpO2
88–92%.*
**5. In diabetic ketoacidosis (DKA), the nurse expects which laboratory
finding?**
- **A) Serum bicarbonate <15 mEq/L**
- B) pH >7.45
- C) PaCO2 >50 mmHg
- D) Glucose 120 mg/dL
- *Rationale: DKA causes metabolic acidosis with low bicarbonate (<15
mEq/L) and low pH. Glucose is usually >250 mg/dL.*
**6. A patient post-MI develops crackles halfway up the lung fields and S3
heart sound. The nurse suspects:**
- A) Cardiogenic shock
, - **B) Left-sided heart failure**
- C) Pericarditis
- D) Pulmonary embolism
- *Rationale: S3 and crackles indicate left ventricular failure with pulmonary
congestion, common after MI.*
**7. Which dietary instruction is appropriate for a patient with chronic kidney
disease (CKD) stage 4?**
- A) Increase dairy products
- **B) Limit phosphorus-rich foods (nuts, beans, cola)**
- C) High-potassium foods (bananas, oranges)
- D) High-protein shakes
- *Rationale: In advanced CKD, phosphorus accumulates, leading to bone
disease. Patients should limit phosphorus and avoid high-protein intake unless
advised otherwise.*
**8. The nurse is caring for a patient with liver cirrhosis and ascites. Which
intervention is most important?**
- A) High-sodium diet
- **B) Daily weight and abdominal girth measurements**
- C) Encourage fluid intake 3 L/day
- D) Place patient supine
vein distention, and 3+ pitting edema in the lower extremities. Which nursing
diagnosis is the priority?**
- A) Impaired Gas Exchange
- **B) Excess Fluid Volume**
- *Rationale: The patient’s crackles, JVD, and edema indicate fluid overload.
Excess Fluid Volume is the priority because it directly contributes to the other
problems like impaired gas exchange.*
**2. A nurse is caring for a client with acute decompensated heart failure
(ADHF) receiving furosemide IV. Which assessment finding requires
immediate action?**
- A) Weight loss of 2 kg in 24 hours
- **B) Serum potassium of 3.0 mEq/L**
- *Rationale: Furosemide causes hypokalemia, which increases the risk of
digoxin toxicity and lethal dysrhythmias. Potassium level of 3.0 is critically low
and needs replacement.*
**3. Which medication is most commonly used as first-line therapy for a patient
with stable angina?**
- **A) Nitroglycerin**
- B) Metoprolol
- C) Amlodipine
- D) Aspirin
,- *Rationale: Nitroglycerin is the first-line agent for acute relief of stable
angina because it vasodilates coronary arteries and reduces preload.*
**4. A patient with chronic obstructive pulmonary disease (COPD) has an
SpO2 of 88%. The nurse should first:**
- A) Apply a non-rebreather mask at 15 L/min
- **B) Administer oxygen via nasal cannula at 2 L/min**
- *Rationale: COPD patients rely on hypoxic drive; high oxygen can cause
CO2 retention and respiratory failure. Start low (2 L/min) and titrate to SpO2
88–92%.*
**5. In diabetic ketoacidosis (DKA), the nurse expects which laboratory
finding?**
- **A) Serum bicarbonate <15 mEq/L**
- B) pH >7.45
- C) PaCO2 >50 mmHg
- D) Glucose 120 mg/dL
- *Rationale: DKA causes metabolic acidosis with low bicarbonate (<15
mEq/L) and low pH. Glucose is usually >250 mg/dL.*
**6. A patient post-MI develops crackles halfway up the lung fields and S3
heart sound. The nurse suspects:**
- A) Cardiogenic shock
, - **B) Left-sided heart failure**
- C) Pericarditis
- D) Pulmonary embolism
- *Rationale: S3 and crackles indicate left ventricular failure with pulmonary
congestion, common after MI.*
**7. Which dietary instruction is appropriate for a patient with chronic kidney
disease (CKD) stage 4?**
- A) Increase dairy products
- **B) Limit phosphorus-rich foods (nuts, beans, cola)**
- C) High-potassium foods (bananas, oranges)
- D) High-protein shakes
- *Rationale: In advanced CKD, phosphorus accumulates, leading to bone
disease. Patients should limit phosphorus and avoid high-protein intake unless
advised otherwise.*
**8. The nurse is caring for a patient with liver cirrhosis and ascites. Which
intervention is most important?**
- A) High-sodium diet
- **B) Daily weight and abdominal girth measurements**
- C) Encourage fluid intake 3 L/day
- D) Place patient supine
