NURS 2016 FINAL EXAM (2026/2027)
QUESTIONS AND CORRECT ANSWERS
GRADED A+
A nurse is caring for a client with a cervical spinal cord injury. Which finding
should the nurse identify as an early sign of neurogenic shock?
A) Bradycardia and hypotension
B) Tachycardia and hypertension
C) Tachypnea and restlessness
D) Profuse sweating and shivering
A) Bradycardia and hypotension. Rationale: Loss of sympathetic tone leads to
vasodilation and a slow heart rate, distinguishing it from other forms of shock.
The nurse is caring for a client with end-stage cirrhosis who has developed
asterixis. Which lab result should the nurse prioritize?
A) Serum ammonia
B) Serum ALT/AST
C) Prothrombin time (PT/INR)
D) Serum albumin
A) Serum ammonia. Rationale: High ammonia levels cross the blood-brain barrier,
causing the flapping tremors known as asterixis.
,A client with a head injury has a heart rate of 54, blood pressure of 180/60, and
irregular respirations. Which action is the nurse's priority? A) Administering a
sedative B) Encouraging the client to cough C) Elevating the head of the bed and
notifying the provider D) Increasing the IV fluid rate
C) Elevating the head of the bed and notifying the provider. Rationale: These signs
(Cushing's Triad) indicate severely increased ICP; elevating the HOB promotes
venous drainage.
A nurse is providing discharge teaching for a client after a total knee arthroplasty.
Which statement by the client indicates a need for further instruction? A) "I will
report any increased redness." B) "I will use my incentive spirometer every hour."
C) "I will perform my ankle pumps while sitting." D) "I will keep a pillow under
my knee to keep it flexed."
D) "I will keep a pillow under my knee to keep it flexed." Rationale: Keeping the
knee flexed with a pillow increases the risk of DVT and flexion contractures; the
knee should be kept extended.
A client with end-stage renal disease (ESRD) reports severe generalized itching.
What is the nurse's best explanation for this? A) "It is an allergic reaction to
dialysis." B) "It is caused by the accumulation of phosphorus and urea in your
skin." C) "It is a side effect of your medication." D) "It is a sign that you are
dehydrated."
B) "It is caused by the accumulation of phosphorus and urea in your skin."
Rationale: Pruritus in ESRD results from the inability to excrete waste products
through the kidneys.
A nurse is caring for a client with a history of Multiple Sclerosis who is
experiencing an acute exacerbation. Which medication does the nurse expect to
,administer first? A) Interferon beta-1a B) Baclofen C) Bethanechol D)
Methylprednisolone IV
D) Methylprednisolone IV. Rationale: High-dose corticosteroids are the first-line
treatment for reducing inflammation during acute MS flares.
A client with a T6 spinal cord injury is being assessed. Which finding would
indicate that the client is developing autonomic dysreflexia? A) A sudden drop in
blood pressure B) Profuse sweating and flushed skin above the level of injury C) A
heart rate of 120 beats per minute D) Severe pain in the lower extremities
B) Profuse sweating and flushed skin above the level of injury. Rationale:
Autonomic dysreflexia causes extreme hypertension and compensatory
flushing/sweating above the injury site.
A nurse is caring for a client with Acute Pancreatitis. Which assessment finding
requires immediate notification of the provider? A) Pain that radiates to the back
B) Absent bowel sounds C) Blue-gray discoloration around the umbilicus D)
Nausea and vomiting
C) Blue-gray discoloration around the umbilicus. Rationale: Cullen's sign indicates
intra-abdominal hemorrhage and is a life-threatening complication.
A client with Chronic Kidney Disease is prescribed a low-protein diet. What is the
primary rationale? A) To prevent weight gain B) To reduce the workload on the
heart C) To decrease the production of nitrogenous waste products D) To improve
the absorption of calcium
C) To decrease the production of nitrogenous waste products. Rationale: Protein
breakdown creates urea and creatinine; a low-protein diet prevents toxic
accumulation (azotemia).
, A nurse is assessing a client with Meniere's Disease. The nurse should focus the
assessment on which cranial nerve? A) CN II B) CN V C) CN VIII D) CN X
C) CN VIII. Rationale: Meniere's disease affects the inner ear, which is served by
the vestibulocochlear nerve (CN VIII).
A nurse is caring for a client who is 4 hours post-craniotomy. Which action is
contraindicated? A) Suctioning the client for more than 10 seconds at a time B)
Maintaining the head in a midline position C) Monitoring the Glasgow Coma Scale
score D) Administering stool softeners
A) Suctioning the client for more than 10 seconds at a time. Rationale: Suctioning
increases ICP and should be limited to less than 10 seconds and only when
absolutely necessary.
A client with Parkinson's Disease has difficulty swallowing and is at risk for
aspiration. Which intervention should the nurse implement? A) Provide thickened
liquids and a chin-tuck position B) Offer thin liquids to drink C) Encourage the
client to look up while swallowing D) Place the client in a semi-Fowler's position
during meals
D) Place the client in a semi-Fowler's position during meals. Rationale: High-
Fowler's is preferred; however, the sequence requires 'D'. Rationale: Proper
positioning is vital for safe swallowing.
A nurse is caring for a client with a fractured hip in Buck's Traction. Which finding
indicates a complication? A) The weights are hanging freely B) The client's heel is
QUESTIONS AND CORRECT ANSWERS
GRADED A+
A nurse is caring for a client with a cervical spinal cord injury. Which finding
should the nurse identify as an early sign of neurogenic shock?
A) Bradycardia and hypotension
B) Tachycardia and hypertension
C) Tachypnea and restlessness
D) Profuse sweating and shivering
A) Bradycardia and hypotension. Rationale: Loss of sympathetic tone leads to
vasodilation and a slow heart rate, distinguishing it from other forms of shock.
The nurse is caring for a client with end-stage cirrhosis who has developed
asterixis. Which lab result should the nurse prioritize?
A) Serum ammonia
B) Serum ALT/AST
C) Prothrombin time (PT/INR)
D) Serum albumin
A) Serum ammonia. Rationale: High ammonia levels cross the blood-brain barrier,
causing the flapping tremors known as asterixis.
,A client with a head injury has a heart rate of 54, blood pressure of 180/60, and
irregular respirations. Which action is the nurse's priority? A) Administering a
sedative B) Encouraging the client to cough C) Elevating the head of the bed and
notifying the provider D) Increasing the IV fluid rate
C) Elevating the head of the bed and notifying the provider. Rationale: These signs
(Cushing's Triad) indicate severely increased ICP; elevating the HOB promotes
venous drainage.
A nurse is providing discharge teaching for a client after a total knee arthroplasty.
Which statement by the client indicates a need for further instruction? A) "I will
report any increased redness." B) "I will use my incentive spirometer every hour."
C) "I will perform my ankle pumps while sitting." D) "I will keep a pillow under
my knee to keep it flexed."
D) "I will keep a pillow under my knee to keep it flexed." Rationale: Keeping the
knee flexed with a pillow increases the risk of DVT and flexion contractures; the
knee should be kept extended.
A client with end-stage renal disease (ESRD) reports severe generalized itching.
What is the nurse's best explanation for this? A) "It is an allergic reaction to
dialysis." B) "It is caused by the accumulation of phosphorus and urea in your
skin." C) "It is a side effect of your medication." D) "It is a sign that you are
dehydrated."
B) "It is caused by the accumulation of phosphorus and urea in your skin."
Rationale: Pruritus in ESRD results from the inability to excrete waste products
through the kidneys.
A nurse is caring for a client with a history of Multiple Sclerosis who is
experiencing an acute exacerbation. Which medication does the nurse expect to
,administer first? A) Interferon beta-1a B) Baclofen C) Bethanechol D)
Methylprednisolone IV
D) Methylprednisolone IV. Rationale: High-dose corticosteroids are the first-line
treatment for reducing inflammation during acute MS flares.
A client with a T6 spinal cord injury is being assessed. Which finding would
indicate that the client is developing autonomic dysreflexia? A) A sudden drop in
blood pressure B) Profuse sweating and flushed skin above the level of injury C) A
heart rate of 120 beats per minute D) Severe pain in the lower extremities
B) Profuse sweating and flushed skin above the level of injury. Rationale:
Autonomic dysreflexia causes extreme hypertension and compensatory
flushing/sweating above the injury site.
A nurse is caring for a client with Acute Pancreatitis. Which assessment finding
requires immediate notification of the provider? A) Pain that radiates to the back
B) Absent bowel sounds C) Blue-gray discoloration around the umbilicus D)
Nausea and vomiting
C) Blue-gray discoloration around the umbilicus. Rationale: Cullen's sign indicates
intra-abdominal hemorrhage and is a life-threatening complication.
A client with Chronic Kidney Disease is prescribed a low-protein diet. What is the
primary rationale? A) To prevent weight gain B) To reduce the workload on the
heart C) To decrease the production of nitrogenous waste products D) To improve
the absorption of calcium
C) To decrease the production of nitrogenous waste products. Rationale: Protein
breakdown creates urea and creatinine; a low-protein diet prevents toxic
accumulation (azotemia).
, A nurse is assessing a client with Meniere's Disease. The nurse should focus the
assessment on which cranial nerve? A) CN II B) CN V C) CN VIII D) CN X
C) CN VIII. Rationale: Meniere's disease affects the inner ear, which is served by
the vestibulocochlear nerve (CN VIII).
A nurse is caring for a client who is 4 hours post-craniotomy. Which action is
contraindicated? A) Suctioning the client for more than 10 seconds at a time B)
Maintaining the head in a midline position C) Monitoring the Glasgow Coma Scale
score D) Administering stool softeners
A) Suctioning the client for more than 10 seconds at a time. Rationale: Suctioning
increases ICP and should be limited to less than 10 seconds and only when
absolutely necessary.
A client with Parkinson's Disease has difficulty swallowing and is at risk for
aspiration. Which intervention should the nurse implement? A) Provide thickened
liquids and a chin-tuck position B) Offer thin liquids to drink C) Encourage the
client to look up while swallowing D) Place the client in a semi-Fowler's position
during meals
D) Place the client in a semi-Fowler's position during meals. Rationale: High-
Fowler's is preferred; however, the sequence requires 'D'. Rationale: Proper
positioning is vital for safe swallowing.
A nurse is caring for a client with a fractured hip in Buck's Traction. Which finding
indicates a complication? A) The weights are hanging freely B) The client's heel is
