Questions and Correct Answer 100% Verified
1. A nurse is assessing a client with dehydration. Which finding is most indicative of fluid
volume deficit?
A. Bounding pulse
B. Peripheral edema
C. Increased urine output
D. Orthostatic hypotension
Correct Answer: D. Orthostatic hypotension
Rationale: Fluid volume deficit decreases circulating blood volume, often causing blood
pressure to drop when the client changes position.
2. A client with diabetes reports shakiness, sweating, and hunger. What should the nurse
do first?
A. Administer insulin
B. Check blood glucose level
C. Restrict oral fluids
D. Notify the provider
Correct Answer: B. Check blood glucose level
Rationale: These symptoms suggest hypoglycemia. The nurse should verify blood glucose
before implementing further interventions.
3. Which laboratory value should concern the nurse most?
A. Sodium 140 mEq/L
B. Potassium 2.8 mEq/L
C. Calcium 9.2 mg/dL
D. Glucose 100 mg/dL
Correct Answer: B. Potassium 2.8 mEq/L
,Rationale: Severe hypokalemia can cause life-threatening cardiac dysrhythmias and requires
prompt intervention.
4. A nurse is caring for a postoperative client. Which finding requires immediate action?
A. Pain rating of 6/10
B. Temperature 37.8°C (100°F)
C. Oxygen saturation 88%
D. Heart rate 102/min
Correct Answer: C. Oxygen saturation 88%
Rationale: Airway and oxygenation are priority concerns according to ABC principles.
5. Which action demonstrates proper hand hygiene?
A. Wash hands only when visibly soiled
B. Use sanitizer for at least 20 seconds when appropriate
C. Wear gloves instead of washing hands
D. Wash hands after patient contact only
Correct Answer: B. Use sanitizer for at least 20 seconds when appropriate
Rationale: Alcohol-based hand rubs are effective when hands are not visibly soiled.
6. A client receiving morphine becomes difficult to arouse and has respirations of 8/min.
Which medication should the nurse anticipate?
A. Flumazenil
B. Naloxone
C. Epinephrine
D. Atropine
Correct Answer: B. Naloxone
Rationale: Naloxone reverses opioid-induced respiratory depression.
7. Which client should the nurse assess first?
, A. Client with chronic pain requesting medication
B. Client with blood pressure 150/90 mmHg
C. Client with chest pain and diaphoresis
D. Client awaiting discharge teaching
Correct Answer: C. Client with chest pain and diaphoresis
Rationale: Possible myocardial infarction requires immediate assessment.
8. What is the priority nursing intervention for a client experiencing anaphylaxis?
A. Obtain allergy history
B. Administer epinephrine as prescribed
C. Start dietary teaching
D. Encourage oral fluids
Correct Answer: B. Administer epinephrine as prescribed
Rationale: Epinephrine rapidly reverses airway edema and hypotension.
9. Which finding is expected in a client with iron-deficiency anemia?
A. Ruddy complexion
B. Elevated hemoglobin
C. Fatigue and pallor
D. Polycythemia
Correct Answer: C. Fatigue and pallor
Rationale: Reduced oxygen-carrying capacity causes weakness, fatigue, and pallor.
10. A nurse is teaching fall prevention. Which statement by the client indicates
understanding?
A. "I will get up quickly to prevent stiffness."
B. "I will call for help before walking if I feel weak."
C. "I do not need nonskid footwear."
D. "Side rails eliminate all fall risks."
Correct Answer: B. "I will call for help before walking if I feel weak."