NGN – Questions and Answers with Rationales
Question 1
A nurse is caring for a client who has heart failure and reports shortness of breath when
lying flat. Which action should the nurse take first?
A. Administer oxygen at 2 L/min
B. Elevate the head of the bed
C. Obtain daily weight
D. Restrict sodium intake
Answer: B. Elevate the head of the bed
Rationale: Positioning the client upright decreases venous return and improves lung
expansion, making it the priority intervention for orthopnea.
Question 2
A nurse is assessing a client who has hypoglycemia. Which finding should the nurse expect?
A. Bradycardia
B. Cool, clammy skin
C. Deep respirations
D. Fruity breath odor
Answer: B. Cool, clammy skin
Rationale: Hypoglycemia activates the sympathetic nervous system, causing diaphoresis,
shakiness, and cool clammy skin.
Question 3
A nurse is teaching a client about warfarin therapy. Which statement by the client indicates
understanding?
,A. “I should increase my intake of spinach.”
B. “I will use an electric razor.”
C. “I can stop the medication when I feel better.”
D. “I should take aspirin for headaches.”
Answer: B. “I will use an electric razor.”
Rationale: Clients taking warfarin are at increased risk for bleeding and should use
measures to reduce injury, such as using an electric razor.
Question 4
A nurse is caring for a client receiving a blood transfusion who develops chills and low back
pain. What is the nurse’s priority action?
A. Slow the infusion rate
B. Stop the transfusion
C. Notify the provider
D. Administer acetaminophen
Answer: B. Stop the transfusion
Rationale: Chills and low back pain suggest a hemolytic transfusion reaction. The
transfusion must be stopped immediately to prevent further complications.
Question 5
A nurse is assessing a newborn 2 hr after birth. Which finding requires immediate
intervention?
A. Respiratory rate 64/min
B. Acrocyanosis
C. Nasal flaring
D. Vernix on the skin
Answer: C. Nasal flaring
,Rationale: Nasal flaring is a sign of respiratory distress in a newborn and requires
immediate evaluation.
Question 6
A nurse is caring for a client with chronic kidney disease. Which laboratory value should the
nurse report immediately?
A. Creatinine 1.8 mg/dL
B. Potassium 6.2 mEq/L
C. Hemoglobin 10 g/dL
D. Calcium 8.2 mg/dL
Answer: B. Potassium 6.2 mEq/L
Rationale: Severe hyperkalemia can cause life-threatening cardiac dysrhythmias and
requires immediate intervention.
Question 7
A nurse is caring for a client receiving morphine IV. Which assessment finding indicates an
adverse effect?
A. Respiratory rate 8/min
B. Blood pressure 130/78 mm Hg
C. Heart rate 88/min
D. Oxygen saturation 96%
Answer: A. Respiratory rate 8/min
Rationale: Respiratory depression is a serious adverse effect of opioid administration.
Question 8
A nurse is teaching a client who has osteoporosis. Which instruction should the nurse
include?
, A. Limit weight-bearing exercise
B. Increase calcium intake
C. Avoid sunlight exposure
D. Reduce protein intake
Answer: B. Increase calcium intake
Rationale: Adequate calcium intake helps maintain bone density and reduce osteoporosis
progression.
Question 9
A nurse is caring for a client following a thyroidectomy. Which finding indicates possible
hypocalcemia?
A. Bradycardia
B. Constipation
C. Positive Chvostek’s sign
D. Hypertension
Answer: C. Positive Chvostek’s sign
Rationale: Hypocalcemia can occur after thyroid surgery due to parathyroid gland damage
and is indicated by neuromuscular irritability such as Chvostek’s sign.
Question 10
A nurse is assessing a client with increased intracranial pressure. Which finding should the
nurse expect?
A. Hypotension
B. Bradycardia
C. Tachypnea
D. Flaccid extremities
Answer: B. Bradycardia