250 NURSING EXAM QUESTIONS WITH
CORRECT ANSWERS AND DETAILED
RATIONALES
1. A nurse is caring for a client with heart failure who is receiving furosemide.
Which laboratory value requires the most immediate intervention?
A. Serum sodium of 135 mEq/L
B. Serum potassium of 3.0 mEq/L
C. Serum calcium of 9.5 mg/dL
D. Serum magnesium of 2.0 mEq/L
Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium wasting. A
potassium of 3.0 mEq/L is critically low (hypokalemia) and can precipitate
fatal cardiac dysrhythmias. The other values are within normal or near-
normal limits.
---
2. A postpartum client reports a gush of blood and a feeling of "something
giving way" while ambulating. The nurse assesses a visible cord protruding
from the vagina. What is the priority nursing action?
A. Apply gentle traction to the cord
,B. Cover the cord with a sterile saline-soaked towel and place the client in
knee-chest position
C. Immediately pack the vagina with sterile gauze
D. Ask the client to bear down to expel the uterus
Answer: B
Rationale: This is an umbilical cord prolapse. The priority is to relieve cord
compression by placing the client in knee-chest or Trendelenburg position
and covering the exposed cord with a sterile saline-soaked towel to maintain
moisture and prevent vasospasm. Traction or packing would worsen the
situation.
---
3. A nurse is preparing to administer digoxin to a client with atrial fibrillation.
Which assessment finding warrants holding the medication and notifying the
provider?
A. Apical pulse of 62 beats/min
B. Serum digoxin level of 1.8 ng/mL
C. Heart rate of 110 beats/min
D. Nausea and halos around lights
Answer: D
Rationale: Nausea, vomiting, and visual disturbances (halos, yellow-green
vision) are classic signs of digoxin toxicity. The therapeutic digoxin level is
0.8–2.0 ng/mL; a pulse of 60 is the typical threshold for holding, but 62 is
acceptable. The client is symptomatic, indicating toxicity.
---
,4. A child with suspected bacterial meningitis is admitted to the pediatric unit.
Which action should the nurse perform first?
A. Initiate droplet precautions
B. Obtain a blood culture
C. Administer prescribed antibiotics
D. Prepare for a lumbar puncture
Answer: A
Rationale: Bacterial meningitis is highly contagious via respiratory droplets.
The nurse must initiate droplet precautions (private room, mask)
immediately upon admission to prevent transmission to staff and other
clients. While the others are important, infection control is the immediate
priority.
---
5. A client with terminal cancer tells the nurse, "I don't want any more chemo.
I just want to go home and die with dignity." Which response by the nurse is
most therapeutic?
A. "You should not give up; there are still new treatments."
B. "Let me call the doctor to discuss your options for palliative care."
C. "Why do you feel that way when your family wants you to fight?"
D. "Everyone feels that way at some point, but it will get better."
Answer: B
Rationale: The nurse acknowledges the client's autonomy and provides
support by facilitating a discussion about palliative care options. This respects
the client's wishes without imposing judgment or false reassurance.
---
, 6. A nurse is caring for a client on continuous enteral tube feeding. The client
develops sudden respiratory distress, cyanosis, and audible wheezing. What is
the nurse's immediate action?
A. Turn off the feeding and place the client in high-Fowler's position
B. Increase the feeding rate to flush the tube
C. Suction the oropharynx
D. Administer a bolus of normal saline
Answer: A
Rationale: These signs indicate aspiration of tube feeding. The nurse must
immediately stop the feeding to prevent further aspiration and elevate the
head of the bed to 90 degrees to minimize reflux and facilitate breathing.
Suctioning may be needed later, but stopping the infusion is primary.
---
7. Which client is at the highest risk for developing deep vein thrombosis
(DVT)?
A. A 25-year-old female on oral contraceptives who runs 5 miles daily
B. A 65-year-old male who is 2 days post-operative hip replacement and
immobile
C. A 45-year-old male with a history of gout
D. A 30-year-old pregnant female with no complications
Answer: B
Rationale: The Virchow's triad (stasis, hypercoagulability, endothelial
damage) is maximized in the post-operative, immobile elderly patient. Hip
surgery specifically increases venous stasis and endothelial injury, placing
him at the highest risk.
CORRECT ANSWERS AND DETAILED
RATIONALES
1. A nurse is caring for a client with heart failure who is receiving furosemide.
Which laboratory value requires the most immediate intervention?
A. Serum sodium of 135 mEq/L
B. Serum potassium of 3.0 mEq/L
C. Serum calcium of 9.5 mg/dL
D. Serum magnesium of 2.0 mEq/L
Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium wasting. A
potassium of 3.0 mEq/L is critically low (hypokalemia) and can precipitate
fatal cardiac dysrhythmias. The other values are within normal or near-
normal limits.
---
2. A postpartum client reports a gush of blood and a feeling of "something
giving way" while ambulating. The nurse assesses a visible cord protruding
from the vagina. What is the priority nursing action?
A. Apply gentle traction to the cord
,B. Cover the cord with a sterile saline-soaked towel and place the client in
knee-chest position
C. Immediately pack the vagina with sterile gauze
D. Ask the client to bear down to expel the uterus
Answer: B
Rationale: This is an umbilical cord prolapse. The priority is to relieve cord
compression by placing the client in knee-chest or Trendelenburg position
and covering the exposed cord with a sterile saline-soaked towel to maintain
moisture and prevent vasospasm. Traction or packing would worsen the
situation.
---
3. A nurse is preparing to administer digoxin to a client with atrial fibrillation.
Which assessment finding warrants holding the medication and notifying the
provider?
A. Apical pulse of 62 beats/min
B. Serum digoxin level of 1.8 ng/mL
C. Heart rate of 110 beats/min
D. Nausea and halos around lights
Answer: D
Rationale: Nausea, vomiting, and visual disturbances (halos, yellow-green
vision) are classic signs of digoxin toxicity. The therapeutic digoxin level is
0.8–2.0 ng/mL; a pulse of 60 is the typical threshold for holding, but 62 is
acceptable. The client is symptomatic, indicating toxicity.
---
,4. A child with suspected bacterial meningitis is admitted to the pediatric unit.
Which action should the nurse perform first?
A. Initiate droplet precautions
B. Obtain a blood culture
C. Administer prescribed antibiotics
D. Prepare for a lumbar puncture
Answer: A
Rationale: Bacterial meningitis is highly contagious via respiratory droplets.
The nurse must initiate droplet precautions (private room, mask)
immediately upon admission to prevent transmission to staff and other
clients. While the others are important, infection control is the immediate
priority.
---
5. A client with terminal cancer tells the nurse, "I don't want any more chemo.
I just want to go home and die with dignity." Which response by the nurse is
most therapeutic?
A. "You should not give up; there are still new treatments."
B. "Let me call the doctor to discuss your options for palliative care."
C. "Why do you feel that way when your family wants you to fight?"
D. "Everyone feels that way at some point, but it will get better."
Answer: B
Rationale: The nurse acknowledges the client's autonomy and provides
support by facilitating a discussion about palliative care options. This respects
the client's wishes without imposing judgment or false reassurance.
---
, 6. A nurse is caring for a client on continuous enteral tube feeding. The client
develops sudden respiratory distress, cyanosis, and audible wheezing. What is
the nurse's immediate action?
A. Turn off the feeding and place the client in high-Fowler's position
B. Increase the feeding rate to flush the tube
C. Suction the oropharynx
D. Administer a bolus of normal saline
Answer: A
Rationale: These signs indicate aspiration of tube feeding. The nurse must
immediately stop the feeding to prevent further aspiration and elevate the
head of the bed to 90 degrees to minimize reflux and facilitate breathing.
Suctioning may be needed later, but stopping the infusion is primary.
---
7. Which client is at the highest risk for developing deep vein thrombosis
(DVT)?
A. A 25-year-old female on oral contraceptives who runs 5 miles daily
B. A 65-year-old male who is 2 days post-operative hip replacement and
immobile
C. A 45-year-old male with a history of gout
D. A 30-year-old pregnant female with no complications
Answer: B
Rationale: The Virchow's triad (stasis, hypercoagulability, endothelial
damage) is maximized in the post-operative, immobile elderly patient. Hip
surgery specifically increases venous stasis and endothelial injury, placing
him at the highest risk.
