2026-Complete Verified Exam Questions with 100%
Verified Correct Answers
Question 1
A competent adult client refuses a blood transfusion for religious reasons. Which actions should
the nurse take? Select all that apply.
A. Verify the client understands risks
B. Document the refusal
C. Administer the transfusion if Hgb is critical
D. Notify the provider
E. Ask the family to override the decision
Correct Answers: A, B, D
Explanation: Competent adults have the right to refuse treatment (autonomy). The nurse must
ensure informed refusal, document the refusal, and notify the provider. Administering against
refusal is battery; family cannot override a competent adult's decision.
Question 2
Which client should the nurse assess first?
A. Post-op day 2 with pain 6/10
B. COPD client with O₂ sat 88% on room air
C. Client waiting for discharge teaching
D. Stable diabetic requesting a snack
Correct Answer: B
Explanation: Airway and oxygenation take priority. An O₂ saturation of 88% indicates
hypoxemia requiring immediate intervention. Pain (6/10) is important but not life-threatening.
Discharge teaching and snack requests are low priority.
Question 3
A nurse is caring for a client with sepsis. Which actions should the nurse take? Select all that
apply.
A. Administer broad-spectrum antibiotics
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,B. Obtain blood cultures
C. Start IV fluids
D. Place client in supine position
E. Decrease room temperature
Correct Answers: A, B, C
Explanation: Sepsis management requires blood cultures before antibiotics, then broad-
spectrum antibiotics, and IV fluid resuscitation to improve perfusion and decrease lactate. Supine
positioning and cooling are not sepsis priorities.
Question 4
Which findings indicate digoxin toxicity? Select all that apply.
A. Bradycardia
B. Green-yellow halos
C. Hypokalemia
D. Tachycardia
E. Hyperkalemia
Correct Answers: A, B, C
Explanation: Low potassium (hypokalemia) increases digoxin toxicity risk. Classic signs
include bradycardia, visual disturbances (green-yellow halos), nausea, and arrhythmias.
Tachycardia and hyperkalemia are not typical.
Question 5
Which task can the RN delegate to an assistive personnel (AP)?
A. Assess pain
B. Reinforce teaching
C. Obtain vital signs on stable client
D. Administer IV antibiotics
Correct Answer: C
Explanation: APs can perform routine, non-assessment tasks like obtaining vital signs on stable
clients. Assessment, teaching, and IV medication administration require licensed nursing
judgment.
Question 6
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,A nurse is reviewing infection control measures. Which interventions prevent infection and
which treat infection? Select the correct pairing.
A. Hand hygiene prevents infection; antibiotics treat infection
B. Hand hygiene treats infection; PPE prevents infection
C. Antibiotics prevent infection; hand hygiene treats infection
D. PPE treats infection; antibiotics prevent infection
Correct Answer: A
Explanation: Hand hygiene and PPE are infection prevention measures. Antibiotics treat
existing bacterial infections, not prevent them.
Question 7
A client reports chest pain radiating to the left arm. What is the first action?
A. Obtain ECG
B. Administer morphine
C. Give oxygen
D. Draw troponin
Correct Answer: A
Explanation: ECG within 10 minutes is priority for suspected MI to identify ST-segment
elevation. Oxygen and morphine follow; troponin is important but not first.
Question 8
A nurse reviews a client's potassium levels over time: 0800: 5.1, 1200: 5.6, 1600: 6.0. What is
the nurse's priority?
A. Document findings
B. Administer loop diuretic
C. Place on cardiac monitor
D. Encourage potassium intake
Correct Answer: C
Explanation: Rising potassium (hyperkalemia) risks life-threatening dysrhythmias. Cardiac
monitoring is priority. Loop diuretics may be ordered but not first; potassium intake should be
restricted.
Question 9
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, Which finding indicates impending respiratory failure?
A. RR 18
B. PaCO₂ rising
C. O₂ sat 95%
D. Clear lung sounds
Correct Answer: B
Explanation: Rising PaCO₂ indicates hypoventilation and impending respiratory failure. Normal
RR, normal O₂ sat, and clear lung sounds are reassuring.
Question 10
Which are expected findings of a left-sided stroke? Select all that apply.
A. Aphasia
B. Right-sided weakness
C. Spatial neglect
D. Impulsive behavior
Correct Answers: A, B
Explanation: Left-brain stroke affects language (aphasia) and right-sided motor function. Spatial
neglect and impulsivity are associated with right-sided stroke.
Question 11
Which lab finding requires immediate follow-up?
A. Creatinine 2.1
B. BUN 18
C. Sodium 138
D. Calcium 9.2
Correct Answer: A
Explanation: Elevated creatinine (normal ~0.6-1.2) indicates impaired kidney function. Other
values are within normal ranges.
Question 12
A client has hypoglycemia. Place the actions in the correct order.
A. Recheck glucose in 15 minutes
B. Administer 15 g of fast-acting carbohydrate
C. Follow with a protein snack
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