SARAH MICHELLE LIVE REVIEW STUDY ON ANCC
EXAM GUIDE ALL TOPIC QUESTIONS, ANSWERS, AND
RATIONALE 2025
Question 1: A patient with chronic obstructive pulmonary disease (COPD) is
admitted to the hospital with acute shortness of breath. What is the priority
intervention for this patient?
Answer:
Administer supplemental oxygen.
Rationale:
For patients with COPD and acute shortness of breath, the priority intervention is
to administer supplemental oxygen to improve oxygen saturation levels. However,
care must be taken to avoid excessive oxygen delivery, as it can suppress
respiratory drive in patients with chronic CO2 retention.
Question 2: A 65-year-old patient presents with confusion, lethargy, and a blood
glucose of 320 mg/dL. The patient has a history of type 2 diabetes. What is the
most likely diagnosis?
Answer:
Hyperglycemic Hyperosmolar Syndrome (HHS).
Rationale:
HHS is commonly seen in older adults with type 2 diabetes, and it is characterized
by high blood glucose levels, dehydration, and altered mental status. Unlike
diabetic ketoacidosis, there is minimal or no ketosis in HHS.
Question 3: What is the most appropriate intervention for a patient experiencing a
panic attack?
Answer:
Encourage the patient to breathe slowly and deeply.
,Rationale:
During a panic attack, hyperventilation can exacerbate symptoms. Encouraging
slow, deep breathing helps reduce anxiety and physical symptoms, including
hyperventilation, and can help the patient regain control.
Question 4: Which of the following is a common side effect of angiotensin-
converting enzyme (ACE) inhibitors?
Answer:
Persistent dry cough.
Rationale:
ACE inhibitors are known to cause a persistent dry cough in some patients due to
the accumulation of bradykinin, a substance that promotes inflammation and
irritation in the airways.
Question 5: A 45-year-old woman presents with symptoms of fatigue, weight
gain, and constipation. Laboratory results show an elevated TSH level and low free
T4. What is the most likely diagnosis?
Answer:
Hypothyroidism.
Rationale:
The elevated TSH (thyroid-stimulating hormone) and low free T4 levels indicate
primary hypothyroidism. The elevated TSH is compensatory in response to low
thyroid hormone levels.
Question 6: A nurse is caring for a postoperative patient who is receiving opioids
for pain management. The patient’s respiratory rate is 8 breaths per minute. What
is the nurse’s priority action?
Answer:
Administer naloxone (Narcan).
,Rationale:
A respiratory rate of 8 breaths per minute is dangerously low and may indicate
opioid-induced respiratory depression. Naloxone is an opioid antagonist that can
rapidly reverse respiratory depression caused by opioid overdose.
Question 7: Which of the following is the most appropriate nursing intervention
for a patient with a history of alcohol abuse who is admitted with delirium tremens
(DTs)?
Answer:
Administer benzodiazepines as ordered.
Rationale:
Delirium tremens is a life-threatening withdrawal syndrome associated with
alcohol dependence. The most effective treatment is the administration of
benzodiazepines, which help manage agitation and prevent seizures.
Question 8: Which of the following is a classic sign of left-sided heart failure?
Answer:
Orthopnea.
Rationale:
Left-sided heart failure leads to pulmonary congestion, which causes symptoms
such as shortness of breath, orthopnea (difficulty breathing while lying flat), and
pulmonary edema.
Question 9: A 30-year-old woman presents with a complaint of palpitations,
excessive sweating, and weight loss despite increased appetite. What diagnostic
test is most likely to confirm the diagnosis of hyperthyroidism?
Answer:
Thyroid scan and uptake.
, Rationale:
A thyroid scan with radioactive iodine uptake is used to evaluate thyroid function
and identify hyperthyroidism. Increased uptake in the thyroid indicates
hyperthyroidism, and it helps differentiate the cause (e.g., Graves' disease).
Question 10: A nurse is caring for a patient who is receiving chemotherapy. The
patient has a platelet count of 25,000/mm³. What is the most important action by
the nurse?
Answer:
Implement bleeding precautions.
Rationale:
A platelet count of 25,000/mm³ is significantly low, and the patient is at risk for
bleeding. Bleeding precautions, such as avoiding invasive procedures, using a soft
toothbrush, and monitoring for signs of bleeding, are essential to minimize risk.
Question 11: A 55-year-old male patient with a history of hypertension presents
with chest pain radiating to his left arm. His blood pressure is 180/100 mmHg, and
his heart rate is 110 bpm. What is the most appropriate first intervention?
Answer:
Administer nitroglycerin as prescribed.
Rationale:
Chest pain, particularly with radiation to the left arm, is a classic sign of acute
myocardial infarction (AMI). Nitroglycerin helps by dilating coronary arteries and
improving blood flow to the heart. It is important to lower blood pressure to reduce
myocardial oxygen demand.
Question 12: A nurse is caring for a postoperative patient who has been
experiencing increasing shortness of breath and a cough productive of pink, frothy
sputum. What complication should the nurse suspect?
EXAM GUIDE ALL TOPIC QUESTIONS, ANSWERS, AND
RATIONALE 2025
Question 1: A patient with chronic obstructive pulmonary disease (COPD) is
admitted to the hospital with acute shortness of breath. What is the priority
intervention for this patient?
Answer:
Administer supplemental oxygen.
Rationale:
For patients with COPD and acute shortness of breath, the priority intervention is
to administer supplemental oxygen to improve oxygen saturation levels. However,
care must be taken to avoid excessive oxygen delivery, as it can suppress
respiratory drive in patients with chronic CO2 retention.
Question 2: A 65-year-old patient presents with confusion, lethargy, and a blood
glucose of 320 mg/dL. The patient has a history of type 2 diabetes. What is the
most likely diagnosis?
Answer:
Hyperglycemic Hyperosmolar Syndrome (HHS).
Rationale:
HHS is commonly seen in older adults with type 2 diabetes, and it is characterized
by high blood glucose levels, dehydration, and altered mental status. Unlike
diabetic ketoacidosis, there is minimal or no ketosis in HHS.
Question 3: What is the most appropriate intervention for a patient experiencing a
panic attack?
Answer:
Encourage the patient to breathe slowly and deeply.
,Rationale:
During a panic attack, hyperventilation can exacerbate symptoms. Encouraging
slow, deep breathing helps reduce anxiety and physical symptoms, including
hyperventilation, and can help the patient regain control.
Question 4: Which of the following is a common side effect of angiotensin-
converting enzyme (ACE) inhibitors?
Answer:
Persistent dry cough.
Rationale:
ACE inhibitors are known to cause a persistent dry cough in some patients due to
the accumulation of bradykinin, a substance that promotes inflammation and
irritation in the airways.
Question 5: A 45-year-old woman presents with symptoms of fatigue, weight
gain, and constipation. Laboratory results show an elevated TSH level and low free
T4. What is the most likely diagnosis?
Answer:
Hypothyroidism.
Rationale:
The elevated TSH (thyroid-stimulating hormone) and low free T4 levels indicate
primary hypothyroidism. The elevated TSH is compensatory in response to low
thyroid hormone levels.
Question 6: A nurse is caring for a postoperative patient who is receiving opioids
for pain management. The patient’s respiratory rate is 8 breaths per minute. What
is the nurse’s priority action?
Answer:
Administer naloxone (Narcan).
,Rationale:
A respiratory rate of 8 breaths per minute is dangerously low and may indicate
opioid-induced respiratory depression. Naloxone is an opioid antagonist that can
rapidly reverse respiratory depression caused by opioid overdose.
Question 7: Which of the following is the most appropriate nursing intervention
for a patient with a history of alcohol abuse who is admitted with delirium tremens
(DTs)?
Answer:
Administer benzodiazepines as ordered.
Rationale:
Delirium tremens is a life-threatening withdrawal syndrome associated with
alcohol dependence. The most effective treatment is the administration of
benzodiazepines, which help manage agitation and prevent seizures.
Question 8: Which of the following is a classic sign of left-sided heart failure?
Answer:
Orthopnea.
Rationale:
Left-sided heart failure leads to pulmonary congestion, which causes symptoms
such as shortness of breath, orthopnea (difficulty breathing while lying flat), and
pulmonary edema.
Question 9: A 30-year-old woman presents with a complaint of palpitations,
excessive sweating, and weight loss despite increased appetite. What diagnostic
test is most likely to confirm the diagnosis of hyperthyroidism?
Answer:
Thyroid scan and uptake.
, Rationale:
A thyroid scan with radioactive iodine uptake is used to evaluate thyroid function
and identify hyperthyroidism. Increased uptake in the thyroid indicates
hyperthyroidism, and it helps differentiate the cause (e.g., Graves' disease).
Question 10: A nurse is caring for a patient who is receiving chemotherapy. The
patient has a platelet count of 25,000/mm³. What is the most important action by
the nurse?
Answer:
Implement bleeding precautions.
Rationale:
A platelet count of 25,000/mm³ is significantly low, and the patient is at risk for
bleeding. Bleeding precautions, such as avoiding invasive procedures, using a soft
toothbrush, and monitoring for signs of bleeding, are essential to minimize risk.
Question 11: A 55-year-old male patient with a history of hypertension presents
with chest pain radiating to his left arm. His blood pressure is 180/100 mmHg, and
his heart rate is 110 bpm. What is the most appropriate first intervention?
Answer:
Administer nitroglycerin as prescribed.
Rationale:
Chest pain, particularly with radiation to the left arm, is a classic sign of acute
myocardial infarction (AMI). Nitroglycerin helps by dilating coronary arteries and
improving blood flow to the heart. It is important to lower blood pressure to reduce
myocardial oxygen demand.
Question 12: A nurse is caring for a postoperative patient who has been
experiencing increasing shortness of breath and a cough productive of pink, frothy
sputum. What complication should the nurse suspect?
