NURS 5366 Module 4 – Detailed Questions, Answers & Rationales A+
Graded (2025_2026)
1. A patient is admitted with dehydration. Which is the nurse’s priority assessment?
✅
A. Skin turgor
B. Blood pressure
C. Weight
D. Urine color
Answer: B. Blood pressure
Rationale: Hypotension indicates reduced intravascular volume and risk for shock, making it
the most urgent assessment. Skin turgor and urine output support assessment but are
secondary.
✅
2. Which patient is at highest risk for hyperkalemia?
A. Patient with chronic kidney disease
B. Patient on loop diuretics
C. Patient with vomiting
D. Healthy adult
Answer: A. Patient with chronic kidney disease
Rationale: Impaired kidney function reduces potassium excretion, increasing hyperkalemia
risk. Loop diuretics cause hypokalemia, vomiting leads to potassium loss, and healthy adults
regulate potassium normally.
✅
3. Which lab value indicates risk for infection?
A. WBC 15,000/mm³
B. Hemoglobin 13 g/dL
C. Platelets 250,000/mm³
D. Sodium 140 mEq/L
,Answer: A. WBC 15,000/mm³
Rationale: Leukocytosis signals inflammation or infection. Other labs are within normal limits
and do not indicate infection.
4. A patient with hypovolemic shock has a BP of 80/50 mmHg and HR 120 bpm. What is
✅
the priority intervention?
A. Administer IV fluids
B. Place in high Fowler’s position
C. Monitor vitals every 4 hours
D. Encourage oral fluids
Answer: A. Administer IV fluids
Rationale: Hypovolemic shock requires rapid intravascular volume replacement. Positioning or
oral intake does not address immediate perfusion needs.
✅
5. Which patient is at highest risk for developing a pressure ulcer?
A. Bedbound patient with limited mobility
B. Ambulatory patient after minor surgery
C. Patient with seasonal allergies
D. Young adult with a cold
Answer: A. Bedbound patient with limited mobility
Rationale: Immobility causes prolonged pressure on bony prominences, leading to skin
breakdown. Frequent repositioning is required for prevention.
6. A patient receiving heparin has an aPTT of 90 seconds (normal 30–40). What is the
✅
priority action?
A. Hold heparin and notify provider
B. Continue heparin as prescribed
C. Monitor daily
D. Increase dose
Answer: A. Hold heparin and notify provider
Rationale: Elevated aPTT indicates increased bleeding risk. Heparin dose must be adjusted to
prevent hemorrhage.
7. Which symptom is an early sign of hypoxia?
A. Cyanosis
, B. Restlessness ✅
C. Bradycardia
D. Hypotension
Answer: B. Restlessness
Rationale: Early hypoxia presents as anxiety or agitation. Cyanosis and bradycardia are late
signs.
✅
8. A patient with heart failure develops pulmonary edema. Which intervention is priority?
A. Administer diuretics as prescribed
B. Encourage oral fluids
C. Elevate legs only
D. Monitor bowel sounds
Answer: A. Administer diuretics as prescribed
Rationale: Diuretics reduce fluid overload in the lungs, improving oxygenation and preventing
respiratory failure.
✅
9. Which lab value suggests hypokalemia?
A. K⁺ 3.0 mEq/L
B. K⁺ 5.5 mEq/L
C. Na⁺ 140 mEq/L
D. Ca²⁺ 9.0 mg/dL
Answer: A. K⁺ 3.0 mEq/L
Rationale: Normal potassium is 3.5–5.0 mEq/L. Hypokalemia can cause arrhythmias, muscle
weakness, and cramping.
10. A patient with diabetes has a fasting glucose of 280 mg/dL. What is the nurse’s
✅
priority action?
A. Administer insulin as prescribed
B. Encourage fluids only
C. Recheck in 24 hours
D. Restrict oral intake
Answer: A. Administer insulin as prescribed
Rationale: Severe hyperglycemia requires intervention to prevent complications such as DKA.
Graded (2025_2026)
1. A patient is admitted with dehydration. Which is the nurse’s priority assessment?
✅
A. Skin turgor
B. Blood pressure
C. Weight
D. Urine color
Answer: B. Blood pressure
Rationale: Hypotension indicates reduced intravascular volume and risk for shock, making it
the most urgent assessment. Skin turgor and urine output support assessment but are
secondary.
✅
2. Which patient is at highest risk for hyperkalemia?
A. Patient with chronic kidney disease
B. Patient on loop diuretics
C. Patient with vomiting
D. Healthy adult
Answer: A. Patient with chronic kidney disease
Rationale: Impaired kidney function reduces potassium excretion, increasing hyperkalemia
risk. Loop diuretics cause hypokalemia, vomiting leads to potassium loss, and healthy adults
regulate potassium normally.
✅
3. Which lab value indicates risk for infection?
A. WBC 15,000/mm³
B. Hemoglobin 13 g/dL
C. Platelets 250,000/mm³
D. Sodium 140 mEq/L
,Answer: A. WBC 15,000/mm³
Rationale: Leukocytosis signals inflammation or infection. Other labs are within normal limits
and do not indicate infection.
4. A patient with hypovolemic shock has a BP of 80/50 mmHg and HR 120 bpm. What is
✅
the priority intervention?
A. Administer IV fluids
B. Place in high Fowler’s position
C. Monitor vitals every 4 hours
D. Encourage oral fluids
Answer: A. Administer IV fluids
Rationale: Hypovolemic shock requires rapid intravascular volume replacement. Positioning or
oral intake does not address immediate perfusion needs.
✅
5. Which patient is at highest risk for developing a pressure ulcer?
A. Bedbound patient with limited mobility
B. Ambulatory patient after minor surgery
C. Patient with seasonal allergies
D. Young adult with a cold
Answer: A. Bedbound patient with limited mobility
Rationale: Immobility causes prolonged pressure on bony prominences, leading to skin
breakdown. Frequent repositioning is required for prevention.
6. A patient receiving heparin has an aPTT of 90 seconds (normal 30–40). What is the
✅
priority action?
A. Hold heparin and notify provider
B. Continue heparin as prescribed
C. Monitor daily
D. Increase dose
Answer: A. Hold heparin and notify provider
Rationale: Elevated aPTT indicates increased bleeding risk. Heparin dose must be adjusted to
prevent hemorrhage.
7. Which symptom is an early sign of hypoxia?
A. Cyanosis
, B. Restlessness ✅
C. Bradycardia
D. Hypotension
Answer: B. Restlessness
Rationale: Early hypoxia presents as anxiety or agitation. Cyanosis and bradycardia are late
signs.
✅
8. A patient with heart failure develops pulmonary edema. Which intervention is priority?
A. Administer diuretics as prescribed
B. Encourage oral fluids
C. Elevate legs only
D. Monitor bowel sounds
Answer: A. Administer diuretics as prescribed
Rationale: Diuretics reduce fluid overload in the lungs, improving oxygenation and preventing
respiratory failure.
✅
9. Which lab value suggests hypokalemia?
A. K⁺ 3.0 mEq/L
B. K⁺ 5.5 mEq/L
C. Na⁺ 140 mEq/L
D. Ca²⁺ 9.0 mg/dL
Answer: A. K⁺ 3.0 mEq/L
Rationale: Normal potassium is 3.5–5.0 mEq/L. Hypokalemia can cause arrhythmias, muscle
weakness, and cramping.
10. A patient with diabetes has a fasting glucose of 280 mg/dL. What is the nurse’s
✅
priority action?
A. Administer insulin as prescribed
B. Encourage fluids only
C. Recheck in 24 hours
D. Restrict oral intake
Answer: A. Administer insulin as prescribed
Rationale: Severe hyperglycemia requires intervention to prevent complications such as DKA.
