HACC NURSING – EXAM QUESTIONS AND ANSWERS | ACCURATE
AND WELL DETAILED | COMPLETE GUIDE & RATIONALES | A+
MATERIAL | NEWEST UPDATE
Core Domains
Fundamentals of Nursing Practice
Medical-Surgical Nursing
Pharmacology and Parenteral Therapy
Maternal-Newborn Nursing
Pediatric Nursing
Mental Health and Psychiatric Nursing
Leadership, Ethics, and Legal Compliance
Community Health and Gerontology
Introduction
This comprehensive practice examination is designed to prepare nursing
candidates for rigorous academic and professional evaluations,
specifically aligning with standards expected in professional nursing
programs. The purpose of this assessment is to evaluate comprehensive
clinical competence, patient safety protocols, and the integration of
nursing theory into practice. The exam rigorously tests core knowledge
across multiple clinical specialties, advanced pharmacology, and legal-
ethical frameworks. Featuring a balanced mix of direct multiple-choice
questions and complex clinical scenarios, the assessment emphasizes
real-world application, critical thinking, and prioritization in high-acuity
healthcare environments. Candidates are challenged to demonstrate safe
decision-making, effective communication, and sound clinical judgment
essential for modern nursing practice.
Question 1
A nurse is caring for a client admitted with acute exacerbation of chronic
obstructive pulmonary disease (COPD). The client appears increasingly
restless, confused, and has a respiratory rate of 28 breaths per minute.
Which of the following initial actions should the nurse take?
A. Administer the prescribed oral sedative to calm the restless client.
B. Increase the nasal cannula oxygen flow rate to 6 L/min immediately.
C. Assess the client's oxygen saturation via pulse oximetry and check
,breath sounds.
D. Place the client in a flat supine position to maximize comfort.
🟢 C. Assess the client's oxygen saturation via pulse oximetry and check
breath sounds.
🔴 Explanation: Restlessness and confusion in a COPD client are classic
early signs of hypoxia and hypercapnia. The nurse must first assess the
clinical status through objective measures like pulse oximetry and lung
auscultation before implementing interventions. High-flow oxygen can
suppress the hypoxic drive in chronic CO2 retainers, and sedatives will
further depress respiration. A flat position worsens dyspnea.
Question 2
An older adult client in a long-term care facility refuses to take a newly
prescribed antihypertensive medication. The client is alert, oriented, and
demonstrates full capacity to make medical decisions. What is the most
appropriate nursing response?
A. Inform the client that the physician ordered the medication and it must
be taken.
B. Crush the medication and mix it into the client's morning applesauce
discreetly.
C. Respect the client's decision, document the refusal, and notify the
prescribing provider.
D. Explain that failure to take the medication will result in immediate
discharge from the facility.
🟢 C. Respect the client's decision, document the refusal, and notify the
prescribing provider.
🔴 Explanation: Competent adult clients have the legal and ethical right
to refuse any medical treatment or medication under the principle of
autonomy. Forcing medication, hiding it in food without consent, or using
coercion violates professional ethics and constitutes battery. The nurse
must advocate for the client, document the refusal accurately, and inform
the provider.
Question 3
A nurse is administering digoxin 0.25 mg orally to a client with heart
failure. Prior to administering the medication, which of the following
assessments is most critical?
,A. Assessing the client's peripheral edema in both lower extremities.
B. Measuring the client's apical pulse for a full minute.
C. Checking the client's most recent serum potassium level.
D. Evaluating the client's daily fluid intake and output records.
🟢 B. Measuring the client's apical pulse for a full minute.
🔴 Explanation: Digoxin has a negative chronotropic effect and can
cause severe bradycardia and toxicity. The nurse must assess the apical
pulse for a full minute and hold the medication if the heart rate is below 60
beats per minute in adults. While potassium levels are important because
hypokalemia potentiates digoxin toxicity, the immediate pre-administration
safety check is the apical heart rate.
Question 4
A postpartum client who delivered a healthy newborn 4 hours ago reports
a sudden trickle of bright red blood from the vagina and dizziness. Upon
assessment, the nurse finds the client's uterus is boggy and located
above the umbilicus and displaced to the right. What is the priority nursing
intervention?
A. Administer methylergonovine intramuscularly as prescribed.
B. Assist the client to ambulate to the bathroom to void.
C. Perform immediate fundal massage and empty the client's bladder.
D. Notify the primary healthcare provider and prepare for a blood
transfusion.
🟢 C. Perform immediate fundal massage and empty the client's bladder.
🔴 Explanation: A boggy uterus displaced to the right strongly indicates a
distended bladder, which prevents the uterus from contracting effectively
and leads to postpartum hemorrhage. The immediate priorities are to
massage the boggy uterus to stimulate contraction and assist the client in
voiding (or catheterize) to relieve bladder distension.
Question 5
A nurse is providing discharge instructions to the parent of a 2-year-old
child prescribed liquid oral iron supplementation for iron deficiency
anemia. Which statement by the parent indicates an understanding of the
teaching?
A. "I will mix the iron drops into a full cup of whole milk to improve taste."
B. "I should administer the iron drops with citrus juice and use a straw."
C. "It is normal for my child's stools to turn a bright red color."
, D. "I can stop the medication as soon as my child's energy levels return to
normal."
🟢 B. I should administer the iron drops with citrus juice and use a straw.
🔴 Explanation: Vitamin C (citrus juice) enhances the absorption of iron.
Using a straw helps prevent staining of the teeth by liquid iron
preparations. Milk products bind to iron and decrease absorption. Stools
typically turn a tarry green or black color, not red. Therapy must be
continued for several months after hemoglobin levels normalize to
replenish iron stores.
Question 6
A nurse is caring for a client diagnosed with paranoid schizophrenia who
states, "The government has planted a tracking device inside my brain
through the television." Which of the following is the most therapeutic
nursing response?
A. "That is not true. No one can put a device in your brain through the
television."
B. "Why do you think the government is trying to track you?"
C. "It must feel very frightening to believe that someone is trying to
monitor you."
D. "Let's turn off the television and focus on a game of cards together."
🟢 C. "It must feel very frightening to believe that someone is trying to
monitor you."
🔴 Explanation: Validating the client's underlying feelings without arguing
with or reinforcing the false belief (delusion) is the most therapeutic
approach. Confronting the delusion directly can cause agitation and
damage the nurse-client relationship, while asking "why" can increase
defensiveness. Acknowledging the emotional reality establishes trust.
Question 7
A client is receiving a continuous intravenous infusion of heparin for the
treatment of deep vein thrombosis. Which of the following laboratory tests
should the nurse monitor to evaluate the therapeutic efficacy of this
therapy?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count
AND WELL DETAILED | COMPLETE GUIDE & RATIONALES | A+
MATERIAL | NEWEST UPDATE
Core Domains
Fundamentals of Nursing Practice
Medical-Surgical Nursing
Pharmacology and Parenteral Therapy
Maternal-Newborn Nursing
Pediatric Nursing
Mental Health and Psychiatric Nursing
Leadership, Ethics, and Legal Compliance
Community Health and Gerontology
Introduction
This comprehensive practice examination is designed to prepare nursing
candidates for rigorous academic and professional evaluations,
specifically aligning with standards expected in professional nursing
programs. The purpose of this assessment is to evaluate comprehensive
clinical competence, patient safety protocols, and the integration of
nursing theory into practice. The exam rigorously tests core knowledge
across multiple clinical specialties, advanced pharmacology, and legal-
ethical frameworks. Featuring a balanced mix of direct multiple-choice
questions and complex clinical scenarios, the assessment emphasizes
real-world application, critical thinking, and prioritization in high-acuity
healthcare environments. Candidates are challenged to demonstrate safe
decision-making, effective communication, and sound clinical judgment
essential for modern nursing practice.
Question 1
A nurse is caring for a client admitted with acute exacerbation of chronic
obstructive pulmonary disease (COPD). The client appears increasingly
restless, confused, and has a respiratory rate of 28 breaths per minute.
Which of the following initial actions should the nurse take?
A. Administer the prescribed oral sedative to calm the restless client.
B. Increase the nasal cannula oxygen flow rate to 6 L/min immediately.
C. Assess the client's oxygen saturation via pulse oximetry and check
,breath sounds.
D. Place the client in a flat supine position to maximize comfort.
🟢 C. Assess the client's oxygen saturation via pulse oximetry and check
breath sounds.
🔴 Explanation: Restlessness and confusion in a COPD client are classic
early signs of hypoxia and hypercapnia. The nurse must first assess the
clinical status through objective measures like pulse oximetry and lung
auscultation before implementing interventions. High-flow oxygen can
suppress the hypoxic drive in chronic CO2 retainers, and sedatives will
further depress respiration. A flat position worsens dyspnea.
Question 2
An older adult client in a long-term care facility refuses to take a newly
prescribed antihypertensive medication. The client is alert, oriented, and
demonstrates full capacity to make medical decisions. What is the most
appropriate nursing response?
A. Inform the client that the physician ordered the medication and it must
be taken.
B. Crush the medication and mix it into the client's morning applesauce
discreetly.
C. Respect the client's decision, document the refusal, and notify the
prescribing provider.
D. Explain that failure to take the medication will result in immediate
discharge from the facility.
🟢 C. Respect the client's decision, document the refusal, and notify the
prescribing provider.
🔴 Explanation: Competent adult clients have the legal and ethical right
to refuse any medical treatment or medication under the principle of
autonomy. Forcing medication, hiding it in food without consent, or using
coercion violates professional ethics and constitutes battery. The nurse
must advocate for the client, document the refusal accurately, and inform
the provider.
Question 3
A nurse is administering digoxin 0.25 mg orally to a client with heart
failure. Prior to administering the medication, which of the following
assessments is most critical?
,A. Assessing the client's peripheral edema in both lower extremities.
B. Measuring the client's apical pulse for a full minute.
C. Checking the client's most recent serum potassium level.
D. Evaluating the client's daily fluid intake and output records.
🟢 B. Measuring the client's apical pulse for a full minute.
🔴 Explanation: Digoxin has a negative chronotropic effect and can
cause severe bradycardia and toxicity. The nurse must assess the apical
pulse for a full minute and hold the medication if the heart rate is below 60
beats per minute in adults. While potassium levels are important because
hypokalemia potentiates digoxin toxicity, the immediate pre-administration
safety check is the apical heart rate.
Question 4
A postpartum client who delivered a healthy newborn 4 hours ago reports
a sudden trickle of bright red blood from the vagina and dizziness. Upon
assessment, the nurse finds the client's uterus is boggy and located
above the umbilicus and displaced to the right. What is the priority nursing
intervention?
A. Administer methylergonovine intramuscularly as prescribed.
B. Assist the client to ambulate to the bathroom to void.
C. Perform immediate fundal massage and empty the client's bladder.
D. Notify the primary healthcare provider and prepare for a blood
transfusion.
🟢 C. Perform immediate fundal massage and empty the client's bladder.
🔴 Explanation: A boggy uterus displaced to the right strongly indicates a
distended bladder, which prevents the uterus from contracting effectively
and leads to postpartum hemorrhage. The immediate priorities are to
massage the boggy uterus to stimulate contraction and assist the client in
voiding (or catheterize) to relieve bladder distension.
Question 5
A nurse is providing discharge instructions to the parent of a 2-year-old
child prescribed liquid oral iron supplementation for iron deficiency
anemia. Which statement by the parent indicates an understanding of the
teaching?
A. "I will mix the iron drops into a full cup of whole milk to improve taste."
B. "I should administer the iron drops with citrus juice and use a straw."
C. "It is normal for my child's stools to turn a bright red color."
, D. "I can stop the medication as soon as my child's energy levels return to
normal."
🟢 B. I should administer the iron drops with citrus juice and use a straw.
🔴 Explanation: Vitamin C (citrus juice) enhances the absorption of iron.
Using a straw helps prevent staining of the teeth by liquid iron
preparations. Milk products bind to iron and decrease absorption. Stools
typically turn a tarry green or black color, not red. Therapy must be
continued for several months after hemoglobin levels normalize to
replenish iron stores.
Question 6
A nurse is caring for a client diagnosed with paranoid schizophrenia who
states, "The government has planted a tracking device inside my brain
through the television." Which of the following is the most therapeutic
nursing response?
A. "That is not true. No one can put a device in your brain through the
television."
B. "Why do you think the government is trying to track you?"
C. "It must feel very frightening to believe that someone is trying to
monitor you."
D. "Let's turn off the television and focus on a game of cards together."
🟢 C. "It must feel very frightening to believe that someone is trying to
monitor you."
🔴 Explanation: Validating the client's underlying feelings without arguing
with or reinforcing the false belief (delusion) is the most therapeutic
approach. Confronting the delusion directly can cause agitation and
damage the nurse-client relationship, while asking "why" can increase
defensiveness. Acknowledging the emotional reality establishes trust.
Question 7
A client is receiving a continuous intravenous infusion of heparin for the
treatment of deep vein thrombosis. Which of the following laboratory tests
should the nurse monitor to evaluate the therapeutic efficacy of this
therapy?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count
