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1. A client with heart failure is prescribed furosemide. Which laboratory value should the
nurse monitor most closely?
A. Sodium
B. Potassium
C. Calcium
D. Glucose
Answer: B. Potassium
Rationale: Loop diuretics such as furosemide cause potassium loss through the
kidneys, increasing the risk of hypokalemia. This can lead to dangerous dysrhythmias,
making potassium the priority laboratory value to monitor.
2. A nurse is assessing a client with hypoglycemia. Which symptom is expected?
A. Fruity breath odor
B. Dry skin
C. Diaphoresis
D. Kussmaul respirations
Answer: C. Diaphoresis
Rationale: Hypoglycemia activates the sympathetic nervous system, causing sweating,
shakiness, and tachycardia. Fruity breath and Kussmaul respirations are associated
with diabetic ketoacidosis.
,3. A postoperative client suddenly develops shortness of breath and chest pain. What is
the nurse’s first action?
A. Obtain a STAT ECG
B. Elevate the head of the bed
C. Notify the provider
D. Administer oxygen
Answer: D. Administer oxygen
Rationale: Airway and breathing are the priority. Oxygen should be applied immediately
to support oxygenation before further diagnostic actions.
4. Which action is appropriate when caring for a client in airborne isolation?
A. Wear a surgical mask
B. Keep door open for ventilation
C. Use an N95 respirator
D. Wear gloves only
Answer: C. Use an N95 respirator
Rationale: Airborne precautions require an N95 respirator to prevent inhalation of
airborne particles such as tuberculosis.
5. A client receiving heparin therapy has a PTT of 90 seconds. What is the nurse’s
priority action?
A. Increase the infusion rate
B. Continue current rate
C. Stop the infusion
D. Administer vitamin K
Answer: C. Stop the infusion
,Rationale: A prolonged PTT indicates increased bleeding risk. Heparin should be
stopped to prevent hemorrhage.
6. Which sign indicates increased intracranial pressure (ICP)?
A. Bradycardia
B. Tachycardia
C. Hypertension with widened pulse pressure
D. Hypotension
Answer: C. Hypertension with widened pulse pressure
Rationale: Cushing’s triad includes hypertension, bradycardia, and irregular
respirations, indicating rising ICP.
7. A nurse is teaching about insulin administration. When should rapid-acting insulin be
given?
A. 30 minutes before meals
B. At bedtime
C. With meals or immediately before eating
D. Two hours after meals
Answer: C. With meals or immediately before eating
Rationale: Rapid-acting insulin works quickly and must be timed with food intake to
prevent hypoglycemia.
8. Which electrolyte imbalance is associated with muscle twitching and tetany?
A. Hyperkalemia
B. Hypocalcemia
C. Hypernatremia
D. Hypermagnesemia
, Answer: B. Hypocalcemia
Rationale: Low calcium increases neuromuscular excitability, leading to tetany and
muscle spasms.
9. A client reports sudden severe calf pain, swelling, and warmth. What condition is
suspected?
A. Arterial insufficiency
B. Deep vein thrombosis
C. Cellulitis
D. Peripheral neuropathy
Answer: B. Deep vein thrombosis
Rationale: Classic signs of DVT include unilateral pain, swelling, warmth, and
tenderness.
10. Which position is best for a client experiencing pulmonary edema?
A. Supine
B. Trendelenburg
C. High Fowler’s
D. Side-lying
Answer: C. High Fowler’s
Rationale: Upright positioning improves lung expansion and decreases venous return,
reducing pulmonary congestion.
11. A client with Addison’s disease is at risk for which complication?
A. Hypernatremia
B. Hypokalemia
C. Addisonian crisis
D. Hyperglycemia