(Proctored)Exam With Actual 120
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2025/2026 /Latest Update/Instant
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1. A client with chronic obstructive pulmonary disease (COPD) reports increased
dyspnea. Which intervention should the nurse implement first?
A. Administer a bronchodilator
B. Encourage fluid intake
C. Place the client in high-Fowler’s position
D. Teach pursed-lip breathing
C. Place the client in high-Fowler’s position
Rationale: High-Fowler’s position promotes lung expansion and facilitates
oxygenation, which should be the priority in a client with increased dyspnea.
2. A nurse is caring for a client who is post-operative day 1 after abdominal surgery. The
client has absent bowel sounds. Which action is most appropriate?
A. Encourage ambulation
B. Insert a nasogastric tube immediately
C. Offer a clear liquid diet
D. Administer a stool softener
A. Encourage ambulation
Rationale: Early ambulation stimulates bowel motility and prevents post-operative
ileus.
3. A client with heart failure is receiving furosemide. Which laboratory value should the
nurse monitor most closely?
A. Sodium
B. Potassium
, C. Calcium
D. Glucose
B. Potassium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia, which may
lead to cardiac arrhythmias.
4. A nurse is preparing to administer a blood transfusion. Which action is a priority?
A. Assess vital signs every 15 minutes
B. Verify the client’s identity and blood product
C. Pre-medicate with acetaminophen
D. Start IV fluids with 5% dextrose
B. Verify the client’s identity and blood product
Rationale: Correct identification is crucial to prevent a hemolytic transfusion
reaction.
5. A client with diabetes mellitus has a blood glucose of 320 mg/dL. Which finding
requires immediate intervention?
A. Polyuria
B. Fruity breath odor
C. Fatigue
D. Dry skin
B. Fruity breath odor
Rationale: Fruity breath indicates ketoacidosis, which is a life-threatening
complication requiring prompt intervention.
6. A nurse is caring for a client with a new colostomy. Which statement indicates the
client understands stoma care?
A. "I will wash the stoma with soap and water daily."
B. "I need to measure my stoma every 6 months."
C. "I will empty the pouch when it is one-third full."
D. "I can use adhesive remover to take the pouch off."
C. "I will empty the pouch when it is one-third full."
Rationale: Emptying the pouch before it is full prevents leakage and skin irritation.
Soap can irritate the stoma; frequent measurement and adhesive remover should
be used carefully.
7. A client is receiving morphine for post-operative pain. Which assessment finding is
most important to report immediately?
A. Nausea
B. Respiratory rate of 8/min
C. Constipation
D. Sedation
B. Respiratory rate of 8/min
, Rationale: Morphine can cause respiratory depression, which is life-threatening
and requires immediate intervention.
8. A nurse is teaching a client with hypertension about dietary modifications. Which
statement indicates understanding?
A. "I will use soy sauce to season my food."
B. "I will choose low-fat dairy products."
C. "I will limit potassium-rich foods."
D. "I will avoid all carbohydrates."
B. "I will choose low-fat dairy products."
Rationale: Low-fat dairy is recommended as part of the DASH diet to help reduce
blood pressure. Soy sauce is high in sodium; potassium-rich foods are usually
encouraged unless contraindicated.
9. A client is scheduled for a colonoscopy. Which instruction should the nurse provide?
A. Stop anticoagulants 1 day before the procedure
B. Take only clear liquids the day before
C. Administer a cleansing enema the morning of the procedure
D. Eat a low-fiber diet the night before
B. Take only clear liquids the day before
Rationale: Clear liquids reduce fecal content and improve visualization during
colonoscopy.
10. A client with chronic kidney disease has hyperkalemia. Which intervention should the
nurse anticipate?
A. Administer furosemide
B. Administer sodium polystyrene sulfonate
C. Restrict fluid intake
D. Encourage high-potassium foods
B. Administer sodium polystyrene sulfonate
Rationale: Sodium polystyrene sulfonate removes potassium from the body via the
GI tract, helping to treat hyperkalemia.
11. A nurse is caring for a client with a chest tube. The drainage system is bubbling
continuously in the water seal chamber. What does this indicate?
A. Normal function
B. Air leak
C. Pneumothorax
D. Obstruction in tubing
B. Air leak
Rationale: Continuous bubbling in the water seal chamber indicates an air leak.
Intermittent bubbling is expected during exhalation.