(VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027
SECTION ONE: QUESTIONS 1–100
A nurse is caring for a client with a suspected diagnosis of Myasthenia Gravis. Which action should
the nurse prioritize to assist in the diagnosis?
A. Assess for pupillary response to light
B. Perform a Tensilon test
C. Evaluate deep tendon reflexes
D. Administer a lumbar puncture
🟢 B. Perform a Tensilon test
🔴 RATIONALE: The Tensilon test involves the administration of edrophonium, which improves
muscle strength in clients with Myasthenia Gravis, confirming the diagnosis.
A client is prescribed lithium carbonate. Which electrolyte imbalance should the nurse monitor for
that may increase the risk of lithium toxicity?
A. Hypernatremia
B. Hypocalcemia
C. Hyponatremia
D. Hyperkalemia
🟢 C. Hyponatremia
🔴 RATIONALE: Lithium is a salt; if sodium levels are low, the body retains lithium, leading to toxic
levels in the bloodstream.
Which finding indicates the development of a complication in a client following a thyroidectomy?
A. Hoarseness when speaking
B. Positive Trousseau's sign
C. Surgical site edema
,D. Pain at the incision site
🟢 B. Positive Trousseau's sign
🔴 RATIONALE: A positive Trousseau's sign indicates hypocalcemia, a potential complication of a
thyroidectomy due to accidental damage to the parathyroid glands.
A nurse is planning care for a client with neutropenia. Which action is most appropriate?
A. Encourage the client to eat fresh salads
B. Screen all visitors for signs of infection
C. Place the client on contact precautions
D. Administer prophylactic antibiotics
🟢 B. Screen all visitors for signs of infection
🔴 RATIONALE: Neutropenic clients are highly susceptible to infection; screening visitors is a
primary method of protecting the client from exogenous pathogens.
A client in the emergency department reports crushing chest pain radiating to the left arm. Which
intervention is the priority?
A. Obtain a 12-lead ECG
B. Administer oxygen
C. Assess vital signs
D. Administer morphine sulfate
🟢 A. Obtain a 12-lead ECG
🔴 RATIONALE: The ECG is the fastest way to confirm a myocardial infarction and determine the
necessary medical intervention.
A nurse is educating a client about warfarin therapy. Which statement by the client indicates an
understanding of the teaching?
A. I will increase my intake of leafy green vegetables
,B. I will use a soft-bristled toothbrush
C. I will take ibuprofen for headaches
D. I will monitor my pulse rate daily
🟢 B. I will use a soft-bristled toothbrush
🔴 RATIONALE: Warfarin increases bleeding risk; a soft toothbrush minimizes trauma to the
gums, preventing bleeding.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min. What is
the physiological rationale for this low-flow rate?
A. Prevents dry mucous membranes
B. Avoids oxygen toxicity
C. Prevents suppression of the hypoxic drive
D. Improves carbon dioxide retention
🟢 C. Prevents suppression of the hypoxic drive
🔴 RATIONALE: Clients with COPD often rely on low oxygen levels to stimulate their respiratory
drive; high-flow oxygen can suppress this drive.
During a mass casualty incident, which client should the nurse triage as "Red" (immediate)?
A. A client with a stable femoral fracture
B. A client with a sucking chest wound
C. A client with multiple superficial abrasions
D. A client who is unresponsive with fixed pupils
🟢 B. A client with a sucking chest wound
🔴 RATIONALE: A sucking chest wound is a life-threatening, time-sensitive emergency that
requires immediate intervention to restore breathing.
, A nurse is caring for a client with acute pancreatitis. Which laboratory finding is most specific to this
diagnosis?
A. Elevated white blood cell count
B. Increased serum amylase
C. Decreased blood glucose
D. Elevated serum creatinine
🟢 B. Increased serum amylase
🔴 RATIONALE: Serum amylase levels rise rapidly in acute pancreatitis due to the inflammation of
the pancreas and release of enzymes.
Which assessment finding in a client with a chest tube indicates a potential air leak?
A. Continuous bubbling in the water-seal chamber
B. Oscillation of the fluid in the water-seal chamber
C. Absence of drainage in the collection chamber
D. Subcutaneous emphysema at the insertion site
🟢 A. Continuous bubbling in the water-seal chamber
🔴 RATIONALE: Bubbling in the water-seal chamber indicates air is entering the system,
suggesting an air leak either from the client or the equipment.
A nurse is caring for a client with Type 1 Diabetes Mellitus. What is the most common cause of
diabetic ketoacidosis (DKA)?
A. Inadequate carbohydrate intake
B. Missed insulin doses or infection
C. Excessive exercise
D. Hypoglycemia
🟢 B. Missed insulin doses or infection