PN 1004 Final Exam with questions and verified
answers with rationale updated 2026
1. A nurse is reviewing the medical record of a client who has a prescription for a diuretic. Which
of the following laboratory values should the nurse monitor?
A. Serum calcium
B. Serum potassium
C. Serum sodium
D. Serum chloride
Answer: B. Serum potassium
Rationale: Diuretics, especially loop and thiazide diuretics, often cause potassium loss (hypokalemia).
Monitoring potassium levels is critical to prevent cardiac dysrhythmias.
2. The nurse is preparing to administer a subcutaneous injection of insulin. Which of the following
angles should the nurse use?
A. 15 degrees
B. 45 degrees
C. 90 degrees
D. 25 degrees
Answer: C. 90 degrees
Rationale: For a subcutaneous injection, a 90-degree angle is used for average-sized clients. A 45-
degree angle is used for thin clients or when only 1/2 inch of tissue can be grasped.
3. Which of the following is the primary purpose of a nurse performing hand hygiene?
A. To remove dirt from the hands
B. To reduce the number of microorganisms on the hands
C. To prevent the spread of infection
D. To comply with hospital policy
Answer: C. To prevent the spread of infection
Rationale: The primary purpose of hand hygiene is to prevent the spread of infection by reducing the
transmission of microorganisms. While it does reduce microorganisms, the ultimate goal is infection
prevention.
4. A client is prescribed a clear liquid diet. Which of the following items should the nurse remove
from the tray?
A. Apple juice
B. Orange gelatin
C. Vanilla ice cream
D. Beef broth
Answer: C. Vanilla ice cream
Rationale: A clear liquid diet consists of liquids that are transparent and liquid at room temperature.
Ice cream is a full liquid and is not allowed on a clear liquid diet.
5. The nurse is assessing a client who is experiencing shortness of breath. Which of the following
positions should the nurse place the client in?
A. Supine
B. Prone
,C. Fowler's
D. Trendelenburg
Answer: C. Fowler's
Rationale: Fowler's position (high or semi-Fowler's) allows for maximum chest expansion and
improves oxygenation by using gravity to lower the diaphragm.
6. Which of the following findings should the nurse identify as a sign of hypokalemia?
A. Muscle weakness
B. Constipation
C. Hypertension
D. Bradycardia
Answer: A. Muscle weakness
Rationale: Hypokalemia (low potassium) causes muscle weakness, fatigue, and cardiac dysrhythmias.
Constipation is a sign of hypercalcemia, and bradycardia is a sign of hyperkalemia.
7. A nurse is preparing to administer an intramuscular (IM) injection to an infant. Which of the
following sites should the nurse select?
A. Deltoid
B. Ventrogluteal
C. Vastus lateralis
D. Dorsogluteal
Answer: C. Vastus lateralis
Rationale: The vastus lateralis is the preferred site for IM injections in infants and children under 3
years old because the muscle is well-developed and there are no major nerves or blood vessels in the
area.
8. The nurse is teaching a client about a low-sodium diet. Which of the following food choices
indicates the client understands the teaching?
A. Canned soup
B. Fresh fruit
C. Ham
D. Pickles
Answer: B. Fresh fruit
Rationale: Fresh fruits are naturally low in sodium. Canned soups, processed meats (ham), and
pickled foods are high in sodium.
9. Which of the following is a normal finding when assessing the respiratory rate of an adult?
A. 8 breaths per minute
B. 12 breaths per minute
C. 24 breaths per minute
D. 30 breaths per minute
Answer: B. 12 breaths per minute
Rationale: The normal respiratory rate for a healthy adult is 12 to 20 breaths per minute.
10. A nurse is caring for a client who has a new prescription for a blood pressure medication.
Which of the following should the nurse assess before administering the medication?
A. Respiratory rate
B. Blood pressure
C. Temperature
D. Oxygen saturation
, Answer: B. Blood pressure
Rationale: Antihypertensive medications lower blood pressure. The nurse must assess the blood
pressure prior to administration to ensure it is safe to give (e.g., not too low).
11. The nurse is performing a sterile dressing change. Which of the following actions maintains
sterility?
A. Placing the sterile field on the client's bed
B. Reaching over the sterile field
C. Holding sterile supplies close to the body
D. Opening the sterile package away from the body
Answer: D. Opening the sterile package away from the body
Rationale: Opening a sterile package away from the body prevents the wrapper from touching non-
sterile surfaces. Reaching over a sterile field contaminates it. The sterile field must be held above
waist level.
12. Which of the following client statements indicates a need for further teaching regarding the
use of a cane?
A. "I will hold the cane on my stronger side."
B. "I will move the cane forward with my weaker leg."
C. "I will move the cane forward with my stronger leg."
D. "I will use the cane for support when I stand up."
Answer: C. "I will move the cane forward with my stronger leg."
Rationale: The cane is moved forward with the weaker leg to provide support. The client should hold
the cane on the stronger side and move the cane and the weaker leg forward together.
13. A nurse is assessing a client for dehydration. Which of the following findings should the nurse
expect?
A. Bounding pulse
B. Moist mucous membranes
C. Poor skin turgor
D. Hypertension
Answer: C. Poor skin turgor
Rationale: Poor skin turgor (tenting) is a classic sign of dehydration. Other signs include dry mucous
membranes, tachycardia, and hypotension.
14. The nurse is administering a medication via a nasogastric (NG) tube. Which of the following
actions should the nurse take?
A. Administer the medication with a large amount of water
B. Check for residual volume before administering
C. Flush the tube with air after administration
D. Mix all medications together before administration
Answer: B. Check for residual volume before administering
Rationale: Checking residual volume helps determine if the tube is in the stomach and if the client is
tolerating feedings. Medications should be administered separately and flushed with water between
each.
15. Which of the following is the correct sequence for performing a physical assessment of the
abdomen?
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
answers with rationale updated 2026
1. A nurse is reviewing the medical record of a client who has a prescription for a diuretic. Which
of the following laboratory values should the nurse monitor?
A. Serum calcium
B. Serum potassium
C. Serum sodium
D. Serum chloride
Answer: B. Serum potassium
Rationale: Diuretics, especially loop and thiazide diuretics, often cause potassium loss (hypokalemia).
Monitoring potassium levels is critical to prevent cardiac dysrhythmias.
2. The nurse is preparing to administer a subcutaneous injection of insulin. Which of the following
angles should the nurse use?
A. 15 degrees
B. 45 degrees
C. 90 degrees
D. 25 degrees
Answer: C. 90 degrees
Rationale: For a subcutaneous injection, a 90-degree angle is used for average-sized clients. A 45-
degree angle is used for thin clients or when only 1/2 inch of tissue can be grasped.
3. Which of the following is the primary purpose of a nurse performing hand hygiene?
A. To remove dirt from the hands
B. To reduce the number of microorganisms on the hands
C. To prevent the spread of infection
D. To comply with hospital policy
Answer: C. To prevent the spread of infection
Rationale: The primary purpose of hand hygiene is to prevent the spread of infection by reducing the
transmission of microorganisms. While it does reduce microorganisms, the ultimate goal is infection
prevention.
4. A client is prescribed a clear liquid diet. Which of the following items should the nurse remove
from the tray?
A. Apple juice
B. Orange gelatin
C. Vanilla ice cream
D. Beef broth
Answer: C. Vanilla ice cream
Rationale: A clear liquid diet consists of liquids that are transparent and liquid at room temperature.
Ice cream is a full liquid and is not allowed on a clear liquid diet.
5. The nurse is assessing a client who is experiencing shortness of breath. Which of the following
positions should the nurse place the client in?
A. Supine
B. Prone
,C. Fowler's
D. Trendelenburg
Answer: C. Fowler's
Rationale: Fowler's position (high or semi-Fowler's) allows for maximum chest expansion and
improves oxygenation by using gravity to lower the diaphragm.
6. Which of the following findings should the nurse identify as a sign of hypokalemia?
A. Muscle weakness
B. Constipation
C. Hypertension
D. Bradycardia
Answer: A. Muscle weakness
Rationale: Hypokalemia (low potassium) causes muscle weakness, fatigue, and cardiac dysrhythmias.
Constipation is a sign of hypercalcemia, and bradycardia is a sign of hyperkalemia.
7. A nurse is preparing to administer an intramuscular (IM) injection to an infant. Which of the
following sites should the nurse select?
A. Deltoid
B. Ventrogluteal
C. Vastus lateralis
D. Dorsogluteal
Answer: C. Vastus lateralis
Rationale: The vastus lateralis is the preferred site for IM injections in infants and children under 3
years old because the muscle is well-developed and there are no major nerves or blood vessels in the
area.
8. The nurse is teaching a client about a low-sodium diet. Which of the following food choices
indicates the client understands the teaching?
A. Canned soup
B. Fresh fruit
C. Ham
D. Pickles
Answer: B. Fresh fruit
Rationale: Fresh fruits are naturally low in sodium. Canned soups, processed meats (ham), and
pickled foods are high in sodium.
9. Which of the following is a normal finding when assessing the respiratory rate of an adult?
A. 8 breaths per minute
B. 12 breaths per minute
C. 24 breaths per minute
D. 30 breaths per minute
Answer: B. 12 breaths per minute
Rationale: The normal respiratory rate for a healthy adult is 12 to 20 breaths per minute.
10. A nurse is caring for a client who has a new prescription for a blood pressure medication.
Which of the following should the nurse assess before administering the medication?
A. Respiratory rate
B. Blood pressure
C. Temperature
D. Oxygen saturation
, Answer: B. Blood pressure
Rationale: Antihypertensive medications lower blood pressure. The nurse must assess the blood
pressure prior to administration to ensure it is safe to give (e.g., not too low).
11. The nurse is performing a sterile dressing change. Which of the following actions maintains
sterility?
A. Placing the sterile field on the client's bed
B. Reaching over the sterile field
C. Holding sterile supplies close to the body
D. Opening the sterile package away from the body
Answer: D. Opening the sterile package away from the body
Rationale: Opening a sterile package away from the body prevents the wrapper from touching non-
sterile surfaces. Reaching over a sterile field contaminates it. The sterile field must be held above
waist level.
12. Which of the following client statements indicates a need for further teaching regarding the
use of a cane?
A. "I will hold the cane on my stronger side."
B. "I will move the cane forward with my weaker leg."
C. "I will move the cane forward with my stronger leg."
D. "I will use the cane for support when I stand up."
Answer: C. "I will move the cane forward with my stronger leg."
Rationale: The cane is moved forward with the weaker leg to provide support. The client should hold
the cane on the stronger side and move the cane and the weaker leg forward together.
13. A nurse is assessing a client for dehydration. Which of the following findings should the nurse
expect?
A. Bounding pulse
B. Moist mucous membranes
C. Poor skin turgor
D. Hypertension
Answer: C. Poor skin turgor
Rationale: Poor skin turgor (tenting) is a classic sign of dehydration. Other signs include dry mucous
membranes, tachycardia, and hypotension.
14. The nurse is administering a medication via a nasogastric (NG) tube. Which of the following
actions should the nurse take?
A. Administer the medication with a large amount of water
B. Check for residual volume before administering
C. Flush the tube with air after administration
D. Mix all medications together before administration
Answer: B. Check for residual volume before administering
Rationale: Checking residual volume helps determine if the tube is in the stomach and if the client is
tolerating feedings. Medications should be administered separately and flushed with water between
each.
15. Which of the following is the correct sequence for performing a physical assessment of the
abdomen?
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
