2026 | Practice Questions with Correct Answers & Detailed
A nurse is caring for a client who is postoperative following a hip arthroplasty. Which finding
should the nurse report to the healthcare provider immediately?
○ A. Pain rated 4 on a scale of 0-10
○ B. Serosanguineous drainage on the dressing
○ C. Swelling and erythema of the calf
○ D. Temperature of 99.2°F (37.3°C)
CORRECT ANSWER: C. Swelling and erythema of the calf
RATIONALE: Swelling and erythema of the calf may indicate a deep vein thrombosis (DVT), a
life-threatening complication following hip surgery. Pain, serosanguineous drainage, and low-
grade fever are expected postoperative findings.
A nurse is providing discharge teaching to a client with a new diagnosis of heart failure. Which
statement by the client indicates a need for further teaching?
○ A. "I will weigh myself every morning before breakfast."
○ B. "I should report a weight gain of 2 pounds in one day."
○ C. "I can stop my medications when I feel better."
○ D. "I should limit my sodium intake."
CORRECT ANSWER: C. "I can stop my medications when I feel better."
RATIONALE: Clients with heart failure should not stop their medications without consulting
their healthcare provider, as this can lead to worsening of the condition. Daily weighing,
reporting weight gain, and limiting sodium are correct self-management strategies.
A nurse is assessing a client who is 2 hours post-appendectomy. Which finding should the
nurse report to the healthcare provider?
,○ A. Heart rate of 88 beats/min
○ B. Respiratory rate of 20 breaths/min
○ C. Blood pressure of 140/90 mmHg
○ D. Temperature of 101.2°F (38.4°C)
CORRECT ANSWER: D. Temperature of 101.2°F (38.4°C)
RATIONALE: An elevated temperature postoperatively may indicate infection. Heart rate of 88,
respiratory rate of 20, and blood pressure of 140/90 are within acceptable ranges or expected.
A nurse is caring for a client with a nasogastric tube. Which finding indicates proper tube
placement?
○ A. The client reports nausea
○ B. The pH of aspirated fluid is 5.0
○ C. The tube is taped to the client's nose
○ D. The tube is connected to suction
CORRECT ANSWER: B. The pH of aspirated fluid is 5.0
RATIONALE: A pH of 5.0 or less confirms gastric placement. Nausea is not a reliable indicator.
Taping and suction do not confirm placement.
A nurse is preparing to administer a blood transfusion to a client. Which action should the
nurse take first?
○ A. Verify the client's identity with another nurse
○ B. Check the client's vital signs
○ C. Obtain the blood product from the blood bank
○ D. Start an IV line with normal saline
CORRECT ANSWER: A. Verify the client's identity with another nurse
RATIONALE: Verifying the client's identity with another nurse is the first and most critical step
to prevent transfusion errors. Vital signs, obtaining blood, and starting an IV are important but
follow identity verification.
,A client with a history of diabetes mellitus type 1 is admitted with diabetic ketoacidosis (DKA).
Which finding should the nurse expect?
○ A. Blood glucose of 120 mg/dL
○ B. Serum pH of 7.35
○ C. Fruity odor to the breath
○ D. Serum bicarbonate of 25 mEq/L
CORRECT ANSWER: C. Fruity odor to the breath
RATIONALE: A fruity odor to the breath (acetone breath) is a classic sign of DKA due to
ketone production. Blood glucose is elevated (above 250 mg/dL), pH is low (<7.30), and
bicarbonate is low (<15 mEq/L).
A nurse is assessing a client who is receiving IV heparin therapy. Which finding indicates a
potential adverse effect?
○ A. Hemoglobin of 14 g/dL
○ B. Hematocrit of 42%
○ C. Platelet count of 80,000/mm³
○ D. Activated partial thromboplastin time (aPTT) of 45 seconds
CORRECT ANSWER: C. Platelet count of 80,000/mm³
RATIONALE: A platelet count of 80,000/mm³ may indicate heparin-induced thrombocytopenia
(HIT), a serious adverse effect of heparin therapy. Hemoglobin, hematocrit, and aPTT of 45
seconds are acceptable.
A nurse is providing teaching to a client with a new diagnosis of hypertension. Which dietary
modification should the nurse recommend?
○ A. Increase intake of processed foods
○ B. Decrease intake of sodium
○ C. Increase intake of red meat
○ D. Decrease intake of fruits and vegetables
CORRECT ANSWER: B. Decrease intake of sodium
RATIONALE: Decreasing sodium intake reduces fluid retention and lowers blood pressure.
Processed foods and red meat are high in sodium. Fruits and vegetables should be increased,
not decreased.
, A client is prescribed warfarin. Which laboratory value should the nurse monitor to evaluate
the effectiveness of the medication?
○ A. Activated partial thromboplastin time (aPTT)
○ B. Prothrombin time (PT) and International Normalized Ratio (INR)
○ C. Platelet count
○ D. Bleeding time
CORRECT ANSWER: B. Prothrombin time (PT) and International Normalized Ratio (INR)
RATIONALE: Warfarin therapy is monitored using PT and INR, with a therapeutic INR typically
between 2-3. aPTT is used for heparin. Platelet count and bleeding time are not specific for
warfarin monitoring.
A nurse is caring for a client with a chest tube. Which finding indicates the chest tube is
functioning properly?
○ A. Continuous bubbling in the water seal chamber
○ B. Intermittent bubbling in the water seal chamber
○ C. No fluctuation in the water seal chamber
○ D. Absence of drainage in the collection chamber
CORRECT ANSWER: B. Intermittent bubbling in the water seal chamber
RATIONALE: Intermittent bubbling indicates that air is being evacuated from the pleural
space, which is normal. Continuous bubbling indicates an air leak. Fluctuation (tidaling) is
expected. Drainage should be present.
A client is prescribed an opioid for chronic pain. Which side effect should the nurse monitor
for?
○ A. Diarrhea
○ B. Tachycardia
○ C. Constipation
○ D. Hyperglycemia
CORRECT ANSWER: C. Constipation