Exam 2025
Reviewed 150 predicted questions and
verified answers with brief but ACCURATE
RATIONALES FOR guaranteed success
2025
1. A nurse is reviewing the laboratory results of a client receiving warfarin. Which result should
the nurse report to the provider immediately?
A. INR 1.2
B. INR 2.5
C. INR 3.8
D. INR 5.2
Correct Answer: D
Rationale: The therapeutic INR range for warfarin is 2.0–3.0. An INR of 5.2 indicates a high risk
of bleeding and requires immediate action.
2. A nurse is reinforcing teaching to a client who has a new prescription for metoprolol. Which
of the following should the nurse include?
A. "Take this medication on an empty stomach."
B. "Check your pulse daily before taking the medication."
C. "Increase your intake of potassium-rich foods."
,D. "You may experience rapid heart rate at first."
Correct Answer: B
Rationale: Metoprolol is a beta-blocker that can cause bradycardia; patients should monitor
their pulse regularly.
3. A client with active tuberculosis is started on isoniazid. What is the priority lab to monitor?
A. BUN and creatinine
B. ALT and AST
C. Hemoglobin
D. White blood cell count
Correct Answer: B
Rationale: Isoniazid can cause hepatotoxicity. Liver function tests (ALT, AST) must be
monitored closely.
4. A nurse is caring for a client with heart failure who reports shortness of breath and has
bilateral crackles. Which prescription should the nurse implement first?
A. Restrict fluids to 1,000 mL/day
B. Weigh the client daily
C. Administer IV furosemide
D. Place the client in high-Fowler's position
Correct Answer: C
Rationale: IV furosemide reduces fluid overload, improving oxygenation quickly. It is the
priority intervention.
5. A nurse is reinforcing teaching with a postpartum client who is bottle-feeding. Which of the
following should the nurse include to prevent breast engorgement?
A. Apply warm compresses to the breasts
B. Massage the breasts twice daily
C. Express small amounts of milk
,D. Wear a supportive bra continuously
Correct Answer: D
Rationale: A supportive bra helps suppress lactation and reduce discomfort from
engorgement.
6. A client who is 30 weeks pregnant reports severe abdominal pain and vaginal bleeding.
What is the priority nursing action?
A. Check for fetal movement
B. Monitor blood pressure
C. Perform a vaginal exam
D. Place the client on her left side
Correct Answer: B
Rationale: The client may be experiencing placental abruption. Monitoring for signs of shock is
priority.
7. A nurse is caring for a client who is receiving chemotherapy. The client’s absolute neutrophil
count (ANC) is 800/mm³. Which instruction is most appropriate?
A. "Avoid fresh fruits and vegetables."
B. "Limit fluid intake to reduce infection risk."
C. "Take acetaminophen every 4 hours."
D. "Use a soft-bristled toothbrush."
Correct Answer: A
Rationale: A low ANC indicates neutropenia. The client is at high risk for infection and should
avoid uncooked foods.
8. A client who is scheduled for surgery states, “I’m not sure I want to go through with this.”
What is the nurse’s next action?
A. Inform the surgeon
B. Reassure the client surgery is safe
C. Continue preparing the client for surgery
, D. Explain the risks of refusing the surgery
Correct Answer: A
Rationale: A client expressing doubt may be withdrawing consent. The surgeon must be
informed immediately.
9. Which of the following should the nurse report immediately in a newborn?
A. Respiratory rate of 46/min
B. Bluish hands and feet
C. Axillary temperature of 36.1°C (97°F)
D. Grunting with nasal flaring
Correct Answer: D
Rationale: Grunting and nasal flaring indicate respiratory distress and must be addressed
urgently.
10. A client is prescribed phenytoin. Which statement by the client indicates a need for further
teaching?
A. “I will not stop taking this medication suddenly.”
B. “I will brush my teeth regularly.”
C. “I can consume alcohol in moderation.”
D. “I will notify my provider if I develop a rash.”
Correct Answer: C
Rationale: Alcohol interacts with phenytoin and increases seizure risk. Avoid completely.
11. A nurse is caring for a client with schizophrenia who reports hearing voices. What is the
nurse’s best response?
A. "What are the voices telling you?"
B. "You should ignore those voices."
C. "I don’t hear anything, but I understand it feels real to you."
D. "Let’s talk about something else."