EXAM QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALES
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Question 1
A nurse is caring for four clients in a medical-surgical unit. Which client should
the nurse assess first?
A. A client with COPD reporting shortness of breath after ambulation
B. A client with heart failure with 2+ bilateral ankle edema
C. A client with diabetes mellitus reporting blood glucose of 240 mg/dL
D. A client post-appendectomy reporting incisional pain rated 6/10
Correct Answer: A
Rationale:
Shortness of breath in a client with COPD suggests potential airway or
oxygenation compromise, which takes priority over chronic findings or pain
management.
Question 2
A client receiving IV heparin therapy has an activated partial thromboplastin time
(aPTT) of 98 seconds. What is the nurse’s priority action?
A. Administer vitamin K
B. Stop the infusion and notify the provider
,C. Increase the infusion rate
D. Recheck the aPTT in 6 hours
Correct Answer: B
Rationale:
An aPTT significantly above therapeutic range indicates high bleeding risk. The
infusion should be stopped and the provider notified immediately.
Question 3
A nurse is preparing to administer digoxin to a client with heart failure. Which
assessment finding requires the nurse to withhold the medication?
A. Apical pulse of 56 beats/min
B. Serum potassium level of 4.2 mEq/L
C. Blood pressure of 138/84 mm Hg
D. Respiratory rate of 18 breaths/min
Correct Answer: A
Rationale:
Digoxin should be withheld if the apical pulse is below 60 beats/min due to risk of
bradycardia and digoxin toxicity.
Question 4
A nurse is delegating tasks to a licensed practical nurse (LPN). Which task is
appropriate to delegate?
A. Initial assessment of a newly admitted client
B. Teaching a client about insulin administration
C. Reinforcing discharge instructions
D. Developing a plan of care
Correct Answer: C
,Rationale:
LPNs may reinforce teaching previously provided by the RN but may not perform
initial assessments, create care plans, or provide initial teaching.
Question 5
A client with type 1 diabetes presents with nausea, vomiting, fruity breath odor,
and a blood glucose level of 480 mg/dL. Which acid–base imbalance does the
nurse anticipate?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis
Correct Answer: D
Rationale:
Diabetic ketoacidosis results in accumulation of ketones, causing metabolic
acidosis.
Question 6
A nurse is reviewing laboratory results for a client receiving furosemide. Which
value requires immediate intervention?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Chloride 101 mEq/L
D. Magnesium 1.9 mg/dL
Correct Answer: B
Rationale:
Furosemide causes potassium loss. Hypokalemia below 3.5 mEq/L increases risk
for dysrhythmias and requires prompt correction.
, Question 7
A client with a chest tube suddenly reports increased shortness of breath. The nurse
notes absent breath sounds on the affected side and tracheal deviation. What
complication is suspected?
A. Pleural effusion
B. Pulmonary embolism
C. Tension pneumothorax
D. Atelectasis
Correct Answer: C
Rationale:
Tracheal deviation and acute respiratory distress indicate tension pneumothorax, a
life-threatening emergency.
Question 8
A nurse is caring for a client receiving morphine IV. Which finding indicates an
adverse effect requiring immediate action?
A. Constipation
B. Pruritus
C. Respiratory rate of 8 breaths/min
D. Sedation
Correct Answer: C
Rationale:
Respiratory depression is a serious opioid complication and requires immediate
intervention.