2026-2027 Exams Includes Frequently Tested Questions
With ELABORATED 100% Correct COMPLETE SOLUTIONS
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1. Where do you find an adult apical pulse?
A. Right 2nd intercostal space
B. Left 5th intercostal space, midclavicular line
C. Left 7th intercostal space, midaxillary line
D. Sternal notch
Rationale: The apical pulse is best auscultated at the point of maximal
impulse, located at the left 5th intercostal space in the midclavicular line.
2. A patient weighed 200 lbs on admission and 209 lbs on day 2. What should
the nurse evaluate for?
A. Muscle gain
B. Fluid retention
C. Constipation
D. Dietary noncompliance
Rationale: A rapid weight gain of this magnitude in a short time frame is
most likely due to fluid retention, not tissue growth.
3. How should a non-ambulatory patient with bilateral hip arthritis be
positioned for a rectal exam?
A. Supine position
B. Lithotomy position
C. Sims position
D. Trendelenburg position
, Rationale: Sims position allows access for a rectal exam while minimizing
strain on the hips, making it appropriate for patients with arthritis.
4. Which of the following is an example of subjective data?
A. Blood pressure reading
B. Feelings, perceptions, and reported symptoms
C. Lab values
D. Wound measurements
Rationale: Subjective data comes from the patient's own report, such as
feelings and perceived symptoms, as opposed to measurable objective
findings.
5. After verifying with 2 identifiers and administering Tylenol for a headache,
what should the nurse do next?
A. Document only
B. Reassess the patient after 30 minutes
C. Notify the physician immediately
D. Administer a second dose
Rationale: Reassessing pain relief after an appropriate interval (about 30
minutes for oral medication) evaluates the medication's effectiveness.
6. A patient on a high dose of opioids for severe pain is showing signs of
opioid toxicity. Which assessment finding would the nurse expect?
A. Hypertension
B. Respiratory depression
C. Tachycardia
D. Hyperthermia
Rationale: Respiratory depression is the hallmark and most dangerous sign
of opioid toxicity.
7. A peripheral IV is used intermittently for medications, not continuous
infusion. How should the nurse care for it?
, A. Leave it dry between uses
B. Flush with 0.9% saline and lock it
C. Flush with heparin only
D. Discontinue between each use
Rationale: An intermittent (saline lock) IV device should be flushed with
0.9% normal saline to maintain patency between medication
administrations.
8. During a head-to-toe assessment, which clinical sign might indicate fluid
overload?
A. Bounding radial pulse
B. Bilateral crackles
C. Warm, dry skin
D. Hyperactive bowel sounds
Rationale: Bilateral crackles on lung auscultation are a key sign of fluid
accumulation in the lungs, often related to fluid overload.
9. True or False: The nurse should instruct the patient to void before receiving
a blood transfusion.
A. False, it's not necessary
B. True, due to fluid overload risk
C. False, only required for pediatric patients
D. True, to obtain a urine sample
Rationale: Emptying the bladder beforehand helps manage output
monitoring and reduces discomfort, especially given the transfusion's fluid
volume and overload risk.
10.Should a piggyback IV medication be hung above or below the primary IV
bag?
A. Below the primary bag
B. At the same level as the primary bag
, C. Above the primary bag
D. It doesn't matter
Rationale: The piggyback bag is hung higher than the primary bag so gravity
allows the secondary medication to infuse first.
11.What does it indicate if an IV site is swollen and pale?
A. Phlebitis
B. Fluid has leaked into the interstitial space (infiltration)
C. Normal healing response
D. Blood clot formation
Rationale: Swelling and pallor at an IV site are classic signs of infiltration,
where fluid has leaked into surrounding tissue rather than the vein.
12.On post-op day one, is serosanguineous wound drainage abnormal?
A. Yes, it indicates infection
B. No, it is normal
C. Yes, it indicates hemorrhage
D. No, but it should be reported immediately
Rationale: Serosanguineous (thin, pink-tinged) drainage is an expected
finding in the early post-operative period.
13.A wound is tunneling and the wound bed is not visible. Can the LPN care for
this wound?
A. Yes, with RN supervision
B. No, this is outside LPN scope of practice
C. Yes, if documented properly
D. Yes, complex wounds are within LPN scope
Rationale: Tunneling wounds with a non-visible wound bed require
assessment and care beyond LPN scope and should be managed by an RN
or wound specialist.