CORRECT QUESTIONS AND VERIFIED
DETAILED RATIONALES ANSWERS
|CURRENTLY TESTING QUESTIONS AND
SOLUTIONS|ALREADY GRADED
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1. A client with heart failure is receiving furosemide. Which assessment finding requires
immediate intervention?
A. Weight loss of 1 kg in 24 hours
B. Serum potassium 2.9 mEq/L
C. Urine output 2,300 mL in 24 hours
D. Blood pressure 118/72 mm Hg
✔ Correct Answer: B. Serum potassium 2.9 mEq/L
Rationale: Furosemide causes potassium loss. K⁺ below 3.5 mEq/L can lead to life-threatening
dysrhythmias, requiring immediate replacement.
2. A postoperative client reports sudden chest pain and shortness of breath. What is the
priority?
A. Administer morphine
B. Increase IV fluids
C. Apply oxygen
D. Check blood glucose
✔ Correct Answer: C. Apply oxygen
Rationale: Sudden chest pain + dyspnea indicates possible pulmonary embolism. First action
is to improve oxygenation before other interventions.
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,3. A COPD client is receiving oxygen at 6 L/min via nasal cannula. What should the nurse do?
A. Continue the oxygen
B. Decrease to 2 L/min
C. Increase to 10 L/min
D. Switch to a non-rebreather mask
✔ Correct Answer: B. Decrease to 2 L/min
Rationale: High O₂ can suppress a COPD client’s hypoxic respiratory drive. Oxygen should be
kept 1–2 L/min.
4. A client with diabetes has cool, clammy skin, tremors, and confusion. What action is
priority?
A. Give 4 oz of juice
B. Call the provider
C. Administer insulin
D. Begin a carb-restricted diet
✔ Correct Answer: A. Give 4 oz of juice
Rationale: These are symptoms of hypoglycemia. Rapid-acting carbohydrates must be given
immediately.
5. The nurse is caring for a client with C. difficile. Which PPE is required?
A. Gloves only
B. Gloves and gown
C. Gloves, gown, and N95
D. Surgical mask and gloves
✔ Correct Answer: B. Gloves and gown
Rationale: C. difficile requires contact precautions: gloves + gown. Hand hygiene must be soap
and water (not alcohol gel).
6. A client with cirrhosis has ascites. Which finding indicates the treatment is effective?
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,A. Decreased abdominal girth
B. Low albumin level
C. Increased ALT/AST
D. Peripheral edema
✔ Correct Answer: A. Decreased abdominal girth
Rationale: Reduction in fluid accumulation shows improvement.
7. Which meal is appropriate for a client with chronic kidney disease?
A. Steak, mashed potatoes, milk
B. Chicken breast, white rice, apple slices
C. Nuts, spinach salad, yogurt
D. Beans, whole-grain bread, banana
✔ Correct Answer: B. Chicken breast, white rice, apple slices
Rationale: CKD diet: low potassium, low phosphorus, moderate protein. Chicken + rice + apple
fits the restrictions.
8. A client with pneumonia has crackles, fever, and O₂ sat 88% on room air. What is the
priority?
A. Start IV fluids
B. Administer oxygen
C. Obtain sputum culture
D. Give antipyretic
✔ Correct Answer: B. Administer oxygen
Rationale: Maintaining oxygenation is the priority.
9. A client taking warfarin reports nosebleeds. Which lab value should the nurse review?
A. BUN
B. Hct
C. INR
D. aPTT
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, ✔ Correct Answer: C. INR
Rationale: INR monitors warfarin. Bleeding risk increases when INR is >3.
10. A client has acute pancreatitis. Which intervention is priority?
A. Place client NPO
B. Give high-fat diet
C. Encourage ambulation
D. Give morphine only after meals
✔ Correct Answer: A. Place client NPO
Rationale: Eating stimulates pancreatic enzyme release, worsening inflammation. NPO
prevents further injury.
11. A client with a newly created colostomy states “I’ll never be able to live a normal life
again.” What is the best response?
A. “You will adapt over time.”
B. “Try not to think about it.”
C. “Why do you feel that way?”
D. “Let me contact the ostomy support nurse for you.”
✔ Correct Answer: D
Rationale: Provides emotional support + resources, promoting adaptation.
12. A client with DKA is receiving insulin. Which lab value indicates therapy is effective?
A. Potassium 6.0 mEq/L
B. Blood pH 7.25
C. Blood glucose 180 mg/dL
D. Bicarbonate 10 mEq/L
✔ Correct Answer: C
Rationale: Target glucose for DKA treatment is 150–200 mg/dL during correction.
13. Which finding in a client with hypothyroidism requires intervention?
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