RN Nursing Exam Vault |
180-Yield Questions with Answers
1. A nurse is caring for a client with increased intracranial pressure (ICP). Which finding
requires immediate intervention?
A) Blood pressure 170/60 mm Hg
B) Decorticate posturing
C) Glasgow Coma Scale score decreasing from 14 to 10
D) Heart rate of 52/min
Correct Answer: C
Rationale: A sudden decrease in Glasgow Coma Scale indicates worsening neurological status
and possible brain herniation.
2. A nurse is assessing a client receiving digoxin. Which finding indicates possible toxicity?
A) Hypertension
B) Yellow-tinged vision
C) Increased appetite
D) Tachycardia
Correct Answer: B
Rationale: Visual disturbances such as yellow vision are classic signs of digoxin toxicity.
3. A client with chronic kidney disease has a potassium level of 6.5 mEq/L. Which
prescription should the nurse implement first?
A) Restrict fluids
B) Administer sodium polystyrene sulfonate
C) Encourage bananas
D) Obtain a urine specimen
Correct Answer: B
Rationale: Hyperkalemia is life-threatening because it can cause fatal dysrhythmias.
4. Which client should the nurse assess first?
A) Client with COPD and oxygen saturation of 90%
B) Client post-op reporting pain 8/10
, C) Client with chest pain and diaphoresis
D) Client requesting assistance to the bathroom
Correct Answer: C
Rationale: Chest pain with diaphoresis may indicate myocardial infarction.
5. A nurse is caring for a client after thyroidectomy. Which finding requires immediate
action?
A) Hoarse voice
B) Tingling around the mouth
C) Pain at incision site
D) Blood pressure 138/82
Correct Answer: B
Rationale: Tingling indicates hypocalcemia from parathyroid damage.
6. A client receiving blood develops chills and flank pain. What is the nurse’s first action?
A) Slow the infusion
B) Stop the transfusion
C) Notify the provider
D) Obtain vital signs
Correct Answer: B
Rationale: Suspected transfusion reaction requires immediate discontinuation.
7. A nurse teaches a client about nitroglycerin. Which statement shows understanding?
A) “I can take up to 3 tablets 5 minutes apart.”
B) “I should swallow the tablet whole.”
C) “I can store tablets in my bathroom.”
D) “I should take it only at bedtime.”
Correct Answer: A
8. A client with SIADH is most likely to have which finding?
A) Hypernatremia
B) Polyuria
C) Hyponatremia
D) Dehydration
,Correct Answer: C
9. Which meal is appropriate for a client taking warfarin?
A) Spinach salad
B) Broccoli and kale smoothie
C) Grilled chicken with rice
D) Large serving of cabbage
Correct Answer: C
10. A nurse is caring for a client with Addison’s disease. Which finding is expected?
A) Hypertension
B) Moon face
C) Hyperkalemia
D) Weight gain
Correct Answer: C
11. A nurse prepares to suction a tracheostomy. What is the maximum suction time?
A) 5 seconds
B) 10 seconds
C) 20 seconds
D) 30 seconds
Correct Answer: B
12. A client with left-sided heart failure is likely to develop:
A) Jugular vein distention
B) Ascites
C) Pulmonary edema
D) Peripheral edema
Correct Answer: C
13. Which finding suggests compartment syndrome?
A) Bounding pulse
, B) Pain unrelieved by medication
C) Warm extremity
D) Bradycardia
Correct Answer: B
14. A nurse is caring for a client with Cushing syndrome. Which finding is expected?
A) Weight loss
B) Bronze skin pigmentation
C) Buffalo hump
D) Hypotension
Correct Answer: C
15. A client with bacterial meningitis should be placed in which isolation?
A) Airborne
B) Contact
C) Droplet
D) Reverse isolation
Correct Answer: C
16. Which electrolyte imbalance causes peaked T waves?
A) Hypokalemia
B) Hyperkalemia
C) Hypocalcemia
D) Hypernatremia
Correct Answer: B
17. A nurse is teaching insulin injection. Which instruction is correct?
A) Shake NPH insulin vigorously
B) Inject insulin into muscle
C) Rotate injection sites
D) Massage site after injection
Correct Answer: C
180-Yield Questions with Answers
1. A nurse is caring for a client with increased intracranial pressure (ICP). Which finding
requires immediate intervention?
A) Blood pressure 170/60 mm Hg
B) Decorticate posturing
C) Glasgow Coma Scale score decreasing from 14 to 10
D) Heart rate of 52/min
Correct Answer: C
Rationale: A sudden decrease in Glasgow Coma Scale indicates worsening neurological status
and possible brain herniation.
2. A nurse is assessing a client receiving digoxin. Which finding indicates possible toxicity?
A) Hypertension
B) Yellow-tinged vision
C) Increased appetite
D) Tachycardia
Correct Answer: B
Rationale: Visual disturbances such as yellow vision are classic signs of digoxin toxicity.
3. A client with chronic kidney disease has a potassium level of 6.5 mEq/L. Which
prescription should the nurse implement first?
A) Restrict fluids
B) Administer sodium polystyrene sulfonate
C) Encourage bananas
D) Obtain a urine specimen
Correct Answer: B
Rationale: Hyperkalemia is life-threatening because it can cause fatal dysrhythmias.
4. Which client should the nurse assess first?
A) Client with COPD and oxygen saturation of 90%
B) Client post-op reporting pain 8/10
, C) Client with chest pain and diaphoresis
D) Client requesting assistance to the bathroom
Correct Answer: C
Rationale: Chest pain with diaphoresis may indicate myocardial infarction.
5. A nurse is caring for a client after thyroidectomy. Which finding requires immediate
action?
A) Hoarse voice
B) Tingling around the mouth
C) Pain at incision site
D) Blood pressure 138/82
Correct Answer: B
Rationale: Tingling indicates hypocalcemia from parathyroid damage.
6. A client receiving blood develops chills and flank pain. What is the nurse’s first action?
A) Slow the infusion
B) Stop the transfusion
C) Notify the provider
D) Obtain vital signs
Correct Answer: B
Rationale: Suspected transfusion reaction requires immediate discontinuation.
7. A nurse teaches a client about nitroglycerin. Which statement shows understanding?
A) “I can take up to 3 tablets 5 minutes apart.”
B) “I should swallow the tablet whole.”
C) “I can store tablets in my bathroom.”
D) “I should take it only at bedtime.”
Correct Answer: A
8. A client with SIADH is most likely to have which finding?
A) Hypernatremia
B) Polyuria
C) Hyponatremia
D) Dehydration
,Correct Answer: C
9. Which meal is appropriate for a client taking warfarin?
A) Spinach salad
B) Broccoli and kale smoothie
C) Grilled chicken with rice
D) Large serving of cabbage
Correct Answer: C
10. A nurse is caring for a client with Addison’s disease. Which finding is expected?
A) Hypertension
B) Moon face
C) Hyperkalemia
D) Weight gain
Correct Answer: C
11. A nurse prepares to suction a tracheostomy. What is the maximum suction time?
A) 5 seconds
B) 10 seconds
C) 20 seconds
D) 30 seconds
Correct Answer: B
12. A client with left-sided heart failure is likely to develop:
A) Jugular vein distention
B) Ascites
C) Pulmonary edema
D) Peripheral edema
Correct Answer: C
13. Which finding suggests compartment syndrome?
A) Bounding pulse
, B) Pain unrelieved by medication
C) Warm extremity
D) Bradycardia
Correct Answer: B
14. A nurse is caring for a client with Cushing syndrome. Which finding is expected?
A) Weight loss
B) Bronze skin pigmentation
C) Buffalo hump
D) Hypotension
Correct Answer: C
15. A client with bacterial meningitis should be placed in which isolation?
A) Airborne
B) Contact
C) Droplet
D) Reverse isolation
Correct Answer: C
16. Which electrolyte imbalance causes peaked T waves?
A) Hypokalemia
B) Hyperkalemia
C) Hypocalcemia
D) Hypernatremia
Correct Answer: B
17. A nurse is teaching insulin injection. Which instruction is correct?
A) Shake NPH insulin vigorously
B) Inject insulin into muscle
C) Rotate injection sites
D) Massage site after injection
Correct Answer: C
