Assessment Questions And Correct
Answers (Verified Answers) Plus Rationales
2027 Q&A | Instant Download Pdf
1. A nurse is caring for a client admitted with community-acquired
pneumonia. Which assessment finding requires immediate
intervention?
A. Temperature of 38.3°C (101°F)
B. Productive cough with yellow sputum
C. Oxygen saturation of 86% on room air
D. White blood cell count of 13,000/mm³
Rationale: An oxygen saturation of 86% indicates significant hypoxemia
and impaired gas exchange, making it the priority assessment finding.
According to the ABCs (Airway, Breathing, Circulation), oxygenation
always takes precedence over fever, infection, or laboratory
abnormalities. Immediate interventions include oxygen therapy and
further respiratory assessment.
, 2. Which assessment finding is most consistent with left-sided heart
failure?
A. Jugular vein distention
B. Crackles heard in both lung bases
C. Hepatomegaly
D. Peripheral edema
Rationale: Left-sided heart failure results in pulmonary congestion
because blood backs up into the lungs. Crackles, dyspnea, orthopnea,
and pulmonary edema are hallmark findings. Right-sided heart failure
typically causes jugular vein distention, hepatomegaly, and peripheral
edema.
3. Which laboratory value should concern the nurse most in a client
receiving warfarin therapy?
A. Hemoglobin 14 g/dL
B. Platelet count 250,000/mm³
C. INR of 5.2
D. Sodium 140 mEq/L
,Rationale: An INR of 5.2 indicates excessive anticoagulation and greatly
increases the risk for spontaneous bleeding. Therapeutic INR values for
most indications range from 2.0 to 3.0. The nurse should notify the
healthcare provider and assess for signs of bleeding immediately.
4. A client with diabetes mellitus reports shaking, sweating, and
confusion. What should the nurse do first?
A. Administer long-acting insulin.
B. Check the client's blood glucose level.
C. Encourage ambulation.
D. Restrict fluids.
Rationale: These symptoms suggest hypoglycemia. The nurse should
first verify the blood glucose level whenever possible. If hypoglycemia is
confirmed or strongly suspected and testing is delayed, rapid treatment
with carbohydrates is indicated. Assessment guides safe intervention.
5. Which electrolyte imbalance places a client at greatest risk for
cardiac dysrhythmias?
A. Mild hypernatremia
B. Mild hypocalcemia
, C. Hyperkalemia
D. Hypermagnesemia
Rationale: Potassium is essential for cardiac electrical conduction.
Elevated potassium levels can cause life-threatening dysrhythmias,
including ventricular fibrillation and cardiac arrest. Continuous cardiac
monitoring is often indicated in significant hyperkalemia.
6. A nurse is teaching a client newly diagnosed with hypertension.
Which statement demonstrates understanding?
A. "I'll stop taking my medication once my blood pressure improves."
B. "Salt substitutes are always safe."
C. "Lifestyle changes and medications may both be necessary."
D. "I only need my blood pressure checked during appointments."
Rationale: Effective hypertension management often requires a
combination of medication adherence and healthy lifestyle
modifications such as diet, exercise, weight management, and smoking
cessation. Hypertension frequently requires lifelong management.
7. Which finding is expected in a client experiencing dehydration?