NHA CEHRS EXAM SCRIPT 2026 UPDATED
QUESTIONS AND CORRECT ANSWERS
▶ The patient's laboratory report today indicates severe hypokalemia, and
the nurse has notified the physician. Nursing assessment indicates that
heart rhythm is regular. What is the most important nursing intervention for
this patient now?
A) Examine sacral area and patient's heels for skin breakdown due to
potential edema.
B) Establish seizure precautions due to potential muscle twitching, cramps,
and seizures.
C) Institute fall precautions due to potential postural hypotension and weak
leg muscles.
D) Raise bed side rails due to potential decreased level of consciousness
and confusion.. Answer: C
Hypokalemia can cause postural hypotension and bilateral muscle
weakness, especially in the lower extremities. Both of these increase the
risk of falls. Hypokalemia does not cause edema, decreased level of
consciousness, or seizures.
▶ A nurse is assessing clients for fluid and electrolyte imbalances. Which
client is at greatest risk for developing hyponatremia?
A) Client taking digoxin (Lanoxin)
B) Client who is NPO receiving intravenous D5W
C) Client taking ibuprofen (Motrin)
D) Client taking a sulfonamide antibiotic. Answer: B
D5W contains no electrolytes. Because the client is not taking any food or
fluids by mouth, normal sodium excretion can lead to hyponatremia. The
antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.
▶ The nurse accidentally administers 10 mg of morphine intravenously to a
client who had been given another dose of morphine, 5 mg IV, about 30
minutes earlier. What action must the nurse be prepared to take?
,A) Assist with intubation.
B) Monitor pain level.
C) Administer oxygen.
D) Administer naloxone (Narcan).. Answer: D
A combined dose of 15 mg of morphine may cause severe respiratory
depression in some clients. Naloxone is an opioid antagonist that can be
used (intravenously) as the first intervention to reverse respiratory
depression due to a morphine overdose. Then administration of oxygen
may be needed if the client's oxygen saturation decreases. Intubation may
occur if the client does not respond to the Narcan, and respiratory
depression becomes a respiratory arrest. Naloxone may be repeated, but
the pain level of the client needs to be monitored because Narcan can
promote withdrawal symptoms.
▶ Which action does the nurse teach a client to reduce the risk for
dehydration?
A) Avoiding the use of glycerin suppositories to manage constipation
B) Maintaining a daily oral intake approximately equal to daily fluid loss
C) Restricting sodium intake to no greater than 4 g/day
D) Maintaining an oral intake of at least 1500 mL/day. Answer: B
Although a fixed oral intake of 1500 mL daily is good, the key to prevention
of dehydration is to match all fluid losses with the same volume for fluid
intake. This is especially true in warm or dry environments, or when
conditions result in greater than usual fluid loss through perspiration or
ventilation.
▶ A client is taking furosemide (Lasix) and becomes confused. Which
potassium level does the nurse correlate with this condition?
A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L. Answer: A
Hypokalemia decreases cerebral function and is manifested by lethargy,
confusion, inability to perform problem-solving tasks, disorientation, and
,coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L,
potassium is too low, and this could lead to neurologic manifestations.
▶ The most appropriate measure for a nurse to use in assessing core body
temperature when there are suspected problems with thermoregulation is
a(n)
A) rectal thermometer.
B) tympanic membrane sensor.
C) temporal thermometer scan.
D) oral thermometer.. Answer: A
The most reliable means available for assessing core temperature is a
rectal temperature, which is considered the standard of practice. An oral
temperature is a common measure but not the most reliable. A temporal
thermometer scan has some limitations and is not the standard. The
tympanic membrane sensor could be used as a second source for
temperature assessment.
▶ A client presents to the emergency department after prolonged exposure
to the cold. The client is shivering, has slurred speech, and is slow to
respond to questions. Which intervention will the nurse prepare for this
client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids. Answer: B
Mild hypothermia is manifested by shivering, slurred speech, poor muscular
coordination, and impaired cognitive abilities. Mild hypothermia may be
treated with dry clothing and warm blankets. Rewarming should occur
slowly by removing wet clothing and providing dry warm blankets first.
Other treatments are secondary and should be used to treat moderate to
severe hypothermia.
▶ The Joint Commission focuses on safety in health care. Which action by
the nurse reflects The Joint Commission's main objective?
A) Performing range-of-motion exercises on the client three times each day
B) Assessing the client's respirations when administering opioids
, C) Delegating to the nursing assistant to give the client a complete bath
daily
D) Ensuring that the client is eating 100% of the meals served to him or
her. Answer: B
It is important for the nurse to assess respirations of the client when
administering opioids because of the possibility of respiratory depression.
The other interventions may or may not be necessary in the care of the
client and do not focus on safety.
▶ What is a priority nursing intervention to prevent falls for an older adult
client with multiple chronic diseases?
A) Requesting that a family member remain with the client to assist in
ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement without assistance
D) Providing assistance to the client in getting out of the bed or chair.
Answer: D
Advanced age and multiple illnesses, particularly those that result in
alterations in sensation, such as diabetes, predispose this client to falls.
The nurse should provide assistance to the client with transfer and
ambulation to prevent falls. The client should not be restrained or
maintained on bedrest without adequate indication. Although family
members are encouraged to visit, their presence around the clock is not
necessary at this point.
▶ The nurse is caring for four clients. Which client assessment is the most
indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision. Answer: B
At times clients are unable to verbalize that they are in pain but there are
indicators that the client may have acute pain such as increased heart rate,
increased blood pressure, increased respirations, sweating, restlessness,
and overall distress. All the other distractors could indicate clients who
QUESTIONS AND CORRECT ANSWERS
▶ The patient's laboratory report today indicates severe hypokalemia, and
the nurse has notified the physician. Nursing assessment indicates that
heart rhythm is regular. What is the most important nursing intervention for
this patient now?
A) Examine sacral area and patient's heels for skin breakdown due to
potential edema.
B) Establish seizure precautions due to potential muscle twitching, cramps,
and seizures.
C) Institute fall precautions due to potential postural hypotension and weak
leg muscles.
D) Raise bed side rails due to potential decreased level of consciousness
and confusion.. Answer: C
Hypokalemia can cause postural hypotension and bilateral muscle
weakness, especially in the lower extremities. Both of these increase the
risk of falls. Hypokalemia does not cause edema, decreased level of
consciousness, or seizures.
▶ A nurse is assessing clients for fluid and electrolyte imbalances. Which
client is at greatest risk for developing hyponatremia?
A) Client taking digoxin (Lanoxin)
B) Client who is NPO receiving intravenous D5W
C) Client taking ibuprofen (Motrin)
D) Client taking a sulfonamide antibiotic. Answer: B
D5W contains no electrolytes. Because the client is not taking any food or
fluids by mouth, normal sodium excretion can lead to hyponatremia. The
antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.
▶ The nurse accidentally administers 10 mg of morphine intravenously to a
client who had been given another dose of morphine, 5 mg IV, about 30
minutes earlier. What action must the nurse be prepared to take?
,A) Assist with intubation.
B) Monitor pain level.
C) Administer oxygen.
D) Administer naloxone (Narcan).. Answer: D
A combined dose of 15 mg of morphine may cause severe respiratory
depression in some clients. Naloxone is an opioid antagonist that can be
used (intravenously) as the first intervention to reverse respiratory
depression due to a morphine overdose. Then administration of oxygen
may be needed if the client's oxygen saturation decreases. Intubation may
occur if the client does not respond to the Narcan, and respiratory
depression becomes a respiratory arrest. Naloxone may be repeated, but
the pain level of the client needs to be monitored because Narcan can
promote withdrawal symptoms.
▶ Which action does the nurse teach a client to reduce the risk for
dehydration?
A) Avoiding the use of glycerin suppositories to manage constipation
B) Maintaining a daily oral intake approximately equal to daily fluid loss
C) Restricting sodium intake to no greater than 4 g/day
D) Maintaining an oral intake of at least 1500 mL/day. Answer: B
Although a fixed oral intake of 1500 mL daily is good, the key to prevention
of dehydration is to match all fluid losses with the same volume for fluid
intake. This is especially true in warm or dry environments, or when
conditions result in greater than usual fluid loss through perspiration or
ventilation.
▶ A client is taking furosemide (Lasix) and becomes confused. Which
potassium level does the nurse correlate with this condition?
A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L. Answer: A
Hypokalemia decreases cerebral function and is manifested by lethargy,
confusion, inability to perform problem-solving tasks, disorientation, and
,coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L,
potassium is too low, and this could lead to neurologic manifestations.
▶ The most appropriate measure for a nurse to use in assessing core body
temperature when there are suspected problems with thermoregulation is
a(n)
A) rectal thermometer.
B) tympanic membrane sensor.
C) temporal thermometer scan.
D) oral thermometer.. Answer: A
The most reliable means available for assessing core temperature is a
rectal temperature, which is considered the standard of practice. An oral
temperature is a common measure but not the most reliable. A temporal
thermometer scan has some limitations and is not the standard. The
tympanic membrane sensor could be used as a second source for
temperature assessment.
▶ A client presents to the emergency department after prolonged exposure
to the cold. The client is shivering, has slurred speech, and is slow to
respond to questions. Which intervention will the nurse prepare for this
client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids. Answer: B
Mild hypothermia is manifested by shivering, slurred speech, poor muscular
coordination, and impaired cognitive abilities. Mild hypothermia may be
treated with dry clothing and warm blankets. Rewarming should occur
slowly by removing wet clothing and providing dry warm blankets first.
Other treatments are secondary and should be used to treat moderate to
severe hypothermia.
▶ The Joint Commission focuses on safety in health care. Which action by
the nurse reflects The Joint Commission's main objective?
A) Performing range-of-motion exercises on the client three times each day
B) Assessing the client's respirations when administering opioids
, C) Delegating to the nursing assistant to give the client a complete bath
daily
D) Ensuring that the client is eating 100% of the meals served to him or
her. Answer: B
It is important for the nurse to assess respirations of the client when
administering opioids because of the possibility of respiratory depression.
The other interventions may or may not be necessary in the care of the
client and do not focus on safety.
▶ What is a priority nursing intervention to prevent falls for an older adult
client with multiple chronic diseases?
A) Requesting that a family member remain with the client to assist in
ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement without assistance
D) Providing assistance to the client in getting out of the bed or chair.
Answer: D
Advanced age and multiple illnesses, particularly those that result in
alterations in sensation, such as diabetes, predispose this client to falls.
The nurse should provide assistance to the client with transfer and
ambulation to prevent falls. The client should not be restrained or
maintained on bedrest without adequate indication. Although family
members are encouraged to visit, their presence around the clock is not
necessary at this point.
▶ The nurse is caring for four clients. Which client assessment is the most
indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision. Answer: B
At times clients are unable to verbalize that they are in pain but there are
indicators that the client may have acute pain such as increased heart rate,
increased blood pressure, increased respirations, sweating, restlessness,
and overall distress. All the other distractors could indicate clients who
