Questions, Answers & Rationales
Question 1
A nurse is caring for a client diagnosed with chronic heart failure.
Which assessment finding indicates worsening left-sided heart
failure?
A. Peripheral edema B. Jugular vein distention C. Crackles in the
lungs D. Hepatomegaly
Correct Answer:
B. Crackles in the lungs
Rationale:
Left-sided heart failure causes blood to back up into the pulmonary
circulation, leading to pulmonary congestion and fluid accumulation
in the lungs. Crackles are a classic sign of pulmonary edema.
Peripheral edema, jugular vein distention, and hepatomegaly are more
commonly associated with right-sided heart failure.
,Question 2
A client with diabetes mellitus is experiencing diaphoresis, tremors,
and confusion. Which action should the nurse take first?
A. Administer insulin B. Check the blood glucose level C.
Encourage exercise D. Restrict fluids
Correct Answer:
B. Check the blood glucose level
Rationale:
The symptoms suggest hypoglycemia. The nurse should first assess
the blood glucose level to confirm the condition before initiating
treatment. Immediate assessment helps guide safe and appropriate
interventions.
Question 3
,A nurse is teaching a client about deep vein thrombosis prevention
after surgery. Which statement by the client indicates understanding?
A. “I should avoid moving my legs.” B. “I will drink less water.” C.
“I should ambulate as soon as possible.” D. “I should massage
my calves daily.”
Correct Answer:
B. “I should ambulate as soon as possible.”
Rationale:
Early ambulation promotes venous return and decreases venous stasis,
reducing the risk for DVT. Massaging the calves may dislodge a clot,
while immobility and dehydration increase thrombosis risk.
Question 4
A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which oxygen flow rate is generally safest
for this client?
, A. 1–2 L/min via nasal cannula B. 6–8 L/min via simple mask C.
10 L/min via nonrebreather mask D. 15 L/min via face tent
Correct Answer:
A. 1–2 L/min via nasal cannula
Rationale:
Clients with COPD may rely on hypoxic drive for respiratory
stimulation. Low-flow oxygen therapy helps prevent suppression of
respiratory drive while improving oxygenation.
Question 5
A nurse is caring for a client experiencing a myocardial infarction.
Which laboratory value is most specific for cardiac muscle injury?
A. Hemoglobin B. Troponin C. Potassium D. Platelet count
Correct Answer:
B. Troponin