Answers], Plus Explained Rationales | 2026 Latest Update | Instant Download
Questions 1–200
1. A nurse is caring for a client who is 2 days post-op abdominal surgery.
Which finding requires immediate action?
A) Incisional pain rated 4/10
B) Temperature 99.2°F (37.3°C)
C) Wound dehiscence with bowel visible
D) Serosanguineous drainage on dressing
Answer C: Wound dehiscence with bowel visible
Rationale: Wound dehiscence with evisceration is a surgical emergency; cover
with sterile saline-moistened gauze.
,2. A client with heart failure is prescribed furosemide. Which electrolyte
imbalance should the nurse monitor closely?
A) Hyperkalemia
B) Hypokalemia
C) Hypermagnesemia
D) Hypercalcemia
Answer B: Hypokalemia
Rationale: Furosemide is a loop diuretic that causes potassium wasting;
monitor for hypokalemia.
3. Which delegation task is appropriate for a licensed practical nurse (LPN)?
A) Administering enteral tube feeding to a stable client
B) Developing the plan of care
C) Performing initial assessment on a new admission
D) Providing client education on insulin self-administration
Answer A: Administering enteral tube feeding to a stable client
Rationale: LPNs can administer enteral feedings and medications to stable
clients; RNs perform initial assessments and teaching.
4. A client is admitted with an exacerbation of COPD. Which arterial blood
gas (ABG) finding is expected?
,A) pH 7.38, PaCO₂ 40, HCO₃ 24
B) pH 7.30, PaCO₂ 55, HCO₃ 30
C) pH 7.48, PaCO₂ 30, HCO₃ 22
D) pH 7.42, PaCO₂ 38, HCO₃ 26
Answer B: pH 7.30, PaCO₂ 55, HCO₃ 30
Rationale: COPD causes respiratory acidosis with metabolic compensation
(elevated HCO₃).
5. A nurse is preparing to administer digoxin to a client with heart failure.
Which assessment finding indicates digoxin toxicity?
A) Heart rate 72 bpm
B) Nausea, vomiting, and visual disturbances
C) Blood pressure 138/88 mmHg
D) Respiratory rate 16/min
Answer B: Nausea, vomiting, and visual disturbances
Rationale: Digoxin toxicity causes GI symptoms (nausea, vomiting), visual
changes, and arrhythmias.
6. Which client is at highest risk for developing a pressure ulcer?
A) A client who ambulates with a walker
B) A bedridden client with urinary incontinence and poor nutrition
, C) A client who uses a wheelchair independently
D) A client who is alert and oriented
Answer B: A bedridden client with urinary incontinence and poor nutrition
Rationale: Immobility, incontinence, and poor nutrition significantly increase
pressure ulcer risk.
7. A nurse is providing care to a client with a tracheostomy. Which action is
correct during suctioning?
A) Apply suction only when withdrawing the catheter
B) Apply suction when inserting the catheter
C) Suction for 30 seconds at a time
D) Hyperoxygenate after suctioning only
Answer A: Apply suction only when withdrawing the catheter
Rationale: Suction on withdrawal, not insertion, to prevent mucosal damage;
limit to 10-15 seconds.
8. A client with diabetes is admitted with diabetic ketoacidosis (DKA). Which
intervention is most important initially?
A) Administer IV potassium
B) Initiate IV fluid resuscitation with 0.9% normal saline
C) Administer subcutaneous insulin