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Lewis Medical-Surgical Nursing 12th Edition
Test Bank | 100 NCLEX-Style Questions with
Detailed Rationales (Harding & Kwong)"
, Question 1
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A 78-year-old client is admitted with pneumonia and reports increasing shortness of breath and
fatigue. The nurse notes decreased breath sounds in the lower lobes and a respiratory rate of 28
breaths/min. The client is on 2 L/min of oxygen via nasal cannula. Arterial blood gas (ABG)
results show pH 7.31, PaCO₂ 50 mmHg, and HCO₃⁻ 24 mEq/L. Which interpretation of the
ABG findings is most accurate?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct answer: B
Rationale: The ABG reveals a low pH and elevated PaCO₂ with a normal bicarbonate level,
indicating uncompensated respiratory acidosis. Pneumonia impairs alveolar gas exchange,
leading to CO₂ retention. The body attempts to compensate by increasing respiratory rate, but
ventilation is still insufficient. Since bicarbonate is not elevated, compensation hasn’t occurred
yet. This excludes metabolic causes or respiratory alkalosis.
Question 2
, A nurse is caring for a client who is post-operative following abdominal surgery. The client
suddenly reports shortness of breath, chest pain, and restlessness. Vital signs reveal a heart rate
of 118 bpm, blood pressure 90/60 mmHg, respiratory rate of 32 breaths/min, and SpO₂ 85% on
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room air. What is the nurse’s priority action?
A. Administer morphine for pain
B. Notify the provider immediately
C. Apply oxygen via non-rebreather mask
D. Place the client in a Trendelenburg position
Correct answer: C
Rationale: The client's symptoms—acute dyspnea, hypoxia, hypotension, and tachycardia—
suggest a potential pulmonary embolism. Immediate oxygen administration is the priority to
improve oxygenation and prevent tissue hypoxia while further interventions are initiated.
Notification of the provider is also necessary, but stabilizing oxygenation takes precedence.
Morphine may help with pain but does not address the critical oxygen deficit. Trendelenburg
positioning is inappropriate and may worsen ventilation.
Question 3
A nurse is caring for a client who has a history of cirrhosis and presents with confusion, asterixis,
and elevated ammonia levels. Which of the following prescriptions should the nurse anticipate to
manage the client’s current symptoms?
A. Administer lactulose
B. Restrict potassium intake
, C. Administer omeprazole
D. Encourage a high-protein diet
Page | 4 Correct answer: A
Rationale: The client is showing signs of hepatic encephalopathy, which results from the
accumulation of ammonia due to impaired liver function. Lactulose is prescribed to reduce serum
ammonia levels by promoting its excretion through the stool. It also acidifies the colon,
converting ammonia to ammonium which is excreted. Restricting potassium is inappropriate
unless the client is hyperkalemic. Omeprazole is used for acid-related disorders and not helpful
in this case. A high-protein diet may worsen encephalopathy by increasing ammonia production.
Question 4
A nurse is reviewing the lab results of a client receiving chemotherapy for breast cancer. The
client's white blood cell (WBC) count is 1,200/mm³. Which action should the nurse take first?
A. Educate the client on bleeding precautions
B. Check the client’s temperature
C. Place the client on a low-residue diet
D. Administer routine vaccinations
Correct answer: B
Rationale: A WBC count of 1,200/mm³ indicates neutropenia, placing the client at high risk for
infection. The first nursing action should be to assess for infection by checking the client’s
Lewis Medical-Surgical Nursing 12th Edition
Test Bank | 100 NCLEX-Style Questions with
Detailed Rationales (Harding & Kwong)"
, Question 1
Page | 2
A 78-year-old client is admitted with pneumonia and reports increasing shortness of breath and
fatigue. The nurse notes decreased breath sounds in the lower lobes and a respiratory rate of 28
breaths/min. The client is on 2 L/min of oxygen via nasal cannula. Arterial blood gas (ABG)
results show pH 7.31, PaCO₂ 50 mmHg, and HCO₃⁻ 24 mEq/L. Which interpretation of the
ABG findings is most accurate?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct answer: B
Rationale: The ABG reveals a low pH and elevated PaCO₂ with a normal bicarbonate level,
indicating uncompensated respiratory acidosis. Pneumonia impairs alveolar gas exchange,
leading to CO₂ retention. The body attempts to compensate by increasing respiratory rate, but
ventilation is still insufficient. Since bicarbonate is not elevated, compensation hasn’t occurred
yet. This excludes metabolic causes or respiratory alkalosis.
Question 2
, A nurse is caring for a client who is post-operative following abdominal surgery. The client
suddenly reports shortness of breath, chest pain, and restlessness. Vital signs reveal a heart rate
of 118 bpm, blood pressure 90/60 mmHg, respiratory rate of 32 breaths/min, and SpO₂ 85% on
Page | 3
room air. What is the nurse’s priority action?
A. Administer morphine for pain
B. Notify the provider immediately
C. Apply oxygen via non-rebreather mask
D. Place the client in a Trendelenburg position
Correct answer: C
Rationale: The client's symptoms—acute dyspnea, hypoxia, hypotension, and tachycardia—
suggest a potential pulmonary embolism. Immediate oxygen administration is the priority to
improve oxygenation and prevent tissue hypoxia while further interventions are initiated.
Notification of the provider is also necessary, but stabilizing oxygenation takes precedence.
Morphine may help with pain but does not address the critical oxygen deficit. Trendelenburg
positioning is inappropriate and may worsen ventilation.
Question 3
A nurse is caring for a client who has a history of cirrhosis and presents with confusion, asterixis,
and elevated ammonia levels. Which of the following prescriptions should the nurse anticipate to
manage the client’s current symptoms?
A. Administer lactulose
B. Restrict potassium intake
, C. Administer omeprazole
D. Encourage a high-protein diet
Page | 4 Correct answer: A
Rationale: The client is showing signs of hepatic encephalopathy, which results from the
accumulation of ammonia due to impaired liver function. Lactulose is prescribed to reduce serum
ammonia levels by promoting its excretion through the stool. It also acidifies the colon,
converting ammonia to ammonium which is excreted. Restricting potassium is inappropriate
unless the client is hyperkalemic. Omeprazole is used for acid-related disorders and not helpful
in this case. A high-protein diet may worsen encephalopathy by increasing ammonia production.
Question 4
A nurse is reviewing the lab results of a client receiving chemotherapy for breast cancer. The
client's white blood cell (WBC) count is 1,200/mm³. Which action should the nurse take first?
A. Educate the client on bleeding precautions
B. Check the client’s temperature
C. Place the client on a low-residue diet
D. Administer routine vaccinations
Correct answer: B
Rationale: A WBC count of 1,200/mm³ indicates neutropenia, placing the client at high risk for
infection. The first nursing action should be to assess for infection by checking the client’s
