100-Question Practice Exam Merged
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Questions 1–50
1. A nurse is caring for a patient diagnosed with chronic heart
failure. Which assessment finding requires immediate
intervention?
A. Mild bilateral ankle edema
B. Weight gain of 1 pound in 24 hours
C. Crackles heard throughout both lung fields
D. Fatigue after ambulation
Correct Answer: C. Crackles heard throughout both lung fields
Rationale: Crackles throughout both lung fields indicate pulmonary
congestion and fluid accumulation, which can rapidly progress to
pulmonary edema and respiratory distress. Immediate intervention is
required to improve oxygenation and reduce fluid overload. Mild
edema, small weight changes, and fatigue are expected findings in
heart failure but are less urgent.
, 2. A patient with diabetes mellitus asks the nurse why rotating
insulin injection sites is important. What is the best response?
A. To reduce the risk of hypoglycemia
B. To prevent lipodystrophy
C. To improve insulin potency
D. To decrease injection pain completely
Correct Answer: B. To prevent lipodystrophy
Rationale: Repeated insulin injections at the same site can lead to
lipodystrophy, which is abnormal fat distribution that interferes with
insulin absorption. Rotating injection sites promotes consistent
absorption and preserves skin integrity.
3. Which electrolyte imbalance is most commonly associated with
cardiac dysrhythmias?
A. Hypercalcemia
B. Hypermagnesemia
C. Hypokalemia
D. Hypernatremia
Correct Answer: C. Hypokalemia
Rationale: Potassium plays a major role in cardiac electrical activity.
Low potassium levels can lead to dangerous dysrhythmias, muscle
weakness, and ECG changes such as flattened T waves and U waves.
4. A patient with chronic obstructive pulmonary disease (COPD)
is receiving oxygen therapy. Which nursing action is most
appropriate?
,A. Administer oxygen at 10 L/min routinely
B. Encourage high-flow oxygen continuously
C. Monitor oxygen saturation closely
D. Discontinue oxygen if saturation exceeds 90%
Correct Answer: C. Monitor oxygen saturation closely
Rationale: Patients with COPD are at risk for oxygen-induced
hypoventilation. The nurse should closely monitor oxygen saturation
and respiratory status to maintain adequate oxygenation without
suppressing respiratory drive.
5. Which laboratory value is most important for the nurse to
monitor in a patient receiving warfarin therapy?
A. Hemoglobin
B. Platelet count
C. International normalized ratio (INR)
D. White blood cell count
Correct Answer: C. International normalized ratio (INR)
Rationale: INR measures the effectiveness of warfarin therapy and
helps determine the risk of bleeding or clotting. Therapeutic INR levels
typically range between 2.0 and 3.0 for most conditions.
6. A patient reports sudden chest pain radiating to the left arm
and jaw. What is the nurse’s priority action?
A. Obtain a diet history
B. Administer prescribed oxygen
C. Encourage ambulation
D. Reassure the patient and leave the room
, Correct Answer: B. Administer prescribed oxygen
Rationale: Chest pain radiating to the arm and jaw suggests
myocardial infarction. Oxygen helps increase myocardial oxygen
supply and is part of immediate emergency management along with
assessment and notification of the provider.
7. Which intervention is most effective in preventing deep vein
thrombosis in postoperative patients?
A. Restricting fluid intake
B. Maintaining bed rest
C. Encouraging early ambulation
D. Applying warm compresses only
Correct Answer: C. Encouraging early ambulation
Rationale: Early ambulation improves venous circulation and
significantly reduces the risk of thrombus formation. Immobility is a
major risk factor for deep vein thrombosis.
8. A nurse is assessing a patient with hypoglycemia. Which
symptom should the nurse expect?
A. Bradycardia
B. Cold, clammy skin
C. Deep respirations
D. Fruity breath odor
Correct Answer: B. Cold, clammy skin
Rationale: Hypoglycemia activates the sympathetic nervous system,
causing diaphoresis, shakiness, anxiety, tachycardia, and cold clammy