Questions and Answers with Rationales
2024/2025
1. A client with pneumonia is receiving IV antibiotics. Which assessment finding
indicates the treatment is effective?
A. Dullness to percussion over the affected lung
B. Productive cough with yellow sputum
C. Respiratory rate decreased from 28 to 18
D. Crackles present in lower lobes
Correct Answer: C
Rationale: A decreased respiratory rate suggests improved gas exchange and
reduced work of breathing, indicating effective antibiotic therapy.
2. A nurse is caring for a client with COPD. Which action should the nurse take
to promote effective gas exchange?
A. Encourage fluid intake of 3,000 mL/day
B. Instruct the client to lie flat when resting
C. Teach pursed-lip breathing
D. Increase oxygen to 6 L/min via nasal cannula
,Correct Answer: C
Rationale: Pursed-lip breathing helps prolong exhalation and prevents airway
collapse, improving gas exchange in clients with COPD.
3. A client with heart failure has an ejection fraction of 35%. What is the most
appropriate nursing diagnosis?
A. Decreased cardiac output
B. Risk for infection
C. Activity intolerance
D. Deficient fluid volume
Correct Answer: A
Rationale: A low ejection fraction indicates impaired cardiac pumping ability,
leading to decreased cardiac output.
4. A client is admitted with fluid volume excess. Which clinical manifestation
should the nurse expect?
A. Dry mucous membranes
B. Bounding pulse
C. Weight loss
D. Hypotension
Correct Answer: B
Rationale: Bounding pulses occur due to increased circulating volume and cardiac
workload in fluid volume excess.
, 5. Which lab value is most important to monitor in a client receiving
furosemide?
A. Magnesium
B. Sodium
C. Potassium
D. Calcium
Correct Answer: C
Rationale: Potassium levels are a priority because furosemide can cause
hypokalemia, leading to arrhythmias.
6. The nurse is assessing a client with respiratory alkalosis. Which clinical
manifestation is expected?
A. Kussmaul respirations
B. Confusion and tingling fingers
C. Warm, flushed skin
D. Bradypnea
Correct Answer: B
Rationale: Respiratory alkalosis leads to decreased CO₂ and calcium ionization,
causing neuromuscular irritability like tingling and confusion.
7. A client with pulmonary edema is receiving furosemide IV. What is the
desired outcome of this therapy?