Actual Questions and Verified Rationalized
Answers, 100% Guarantee Pass
Q001:
Type: NGN - Extended Multiple Response
Scenario Context: Ms. Howard, 68 y, POD2 after open aortic aneurysm repair, on
morphine PCA, wants to dangle for first time.
Question: Which assessments indicate the nurse should postpone dangling? Select ALL
that apply.
Options:
A. SBP drops 24 mmHg from baseline
B. Patient reports pain 5/10
C. 220 mL serosanguinous JP drain output in last 8 h
D. Patient states “I feel dizzy.”
E. O₂ sat 92 % on 2 L NC
F. HR 108 sinus
(Correct: A, C, D)
Rationale:
, ● Answer: A, C, D
● Why (2026 Rationalization): A drop ≥20 mmHg signals orthostatic intolerance;
>100 mL/h drainage suggests hypovolemia; self-reported dizziness is a red-flag
for syncope.
● Errors: B—5/10 pain is acceptable for activity; E—92 % is adequate with O₂;
F—mild tachycardia alone is not a contraindication if stable.
Q002:
Type: NGN - Matrix
Scenario Context: Same patient now cleared to ambulate.
Question: Match nursing action to rationale for safe ambulation.
Matrix:
Row 1: Apply non-skid footwear
Row 2: Dangle 2 min
Row 3: Encourage slow deep breaths
Row 4: Use rolling IV pole
Columns: A. Prevent fall, B. Reduce orthostatic drop, C. Minimize atelectasis, D.
Maintain line patency
(Correct: Row1-A, Row2-B, Row3-C, Row4-D)
Rationale:
● Answer: As above
● Why (2026 Rationalization): Evidence-based safety bundle reduces post-op
complications by aligning intervention with physiologic goal.
, ● Errors: Any cross-mapping misaligns intervention with outcome (e.g., footwear
does not affect atelectasis).
Q003:
Type: Stand-Alone
Scenario Context: New admit NPO midnight for OR.
Question: Priority when obtaining pre-op vitals?
Options:
A. Compare with baseline
B. Record within 3 min
C. Report temp 37.1 °C
D. Recheck if BP 138/86
(Correct: A)
Rationale:
● Answer: A
● Why (2026 Rationalization): Trend recognition guides anesthesia plan; isolated
values require context.
● Errors: B—timing flexible; C—afebrile; D—isolated mild HTN not critical.
Q004:
Type: NGN - Bowtie
Scenario Context: 7-day-old infant, circumcision site yellow exudate, mother worried.
, Left: Interpretation; Center: Action; Right: Risk.
Left: A. Normal healing, B. Infection, C. Ammonia burn, D. Dehiscence
Center: 1. Culture site, 2. Apply petroleum gauze, 3. Teach normal, 4. Give
acetaminophen
Right: i. Sepsis, ii. Bleeding, iii. Adhesions, iv. Pain
(Correct: B-1-i)
Rationale:
● Answer: B-1-i
● Why (2026 Rationalization): Yellow exudate after 24 h suggests bacterial
colonization; culture guides antibiotics; neonates progress to sepsis rapidly.
● Errors: A-3-iii delays treatment; C-2-ii misidentifies cause; D-4-iv focuses only on
pain.
Q005:
Type: NGN - Drag-and-Drop (Sequence)
Scenario Context: Nurse preparing intermittent NG feeding.
Question: Place steps to verify placement before feeding.
Drag items: Aspirate fluid, Measure pH, Check external mark, Ask patient to speak,
Flush 30 mL
(Correct Sequence: Ask to speak → Check mark → Aspirate → pH → Flush)
Rationale:
● Answer: Sequence above