EXAM PRACTICE QUESTIONS WITH
CORRECT ANSWERS (VERIFIED ANSWERS)
PLUS RATIONALES 2026 Q&A | INSTANT
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1. A nurse is caring for a client admitted with an acute ischemic stroke. Which
action has the highest priority?
A. Determine the time the symptoms began.
B. Obtain the client's weight.
C. Insert an indwelling urinary catheter.
D. Encourage oral fluids.
CORRECT ANSWER: A — Determine the time the symptoms began.
RATIONALE: The onset time determines eligibility for thrombolytic therapy and guides
emergency treatment.
2. A client receiving a continuous heparin infusion has an aPTT of 98 seconds.
Which action should the nurse anticipate?
A. Hold or reduce the infusion per protocol and notify the healthcare provider.
B. Increase the infusion rate.
C. Administer vitamin K.
D. Give aspirin.
CORRECT ANSWER: A — Hold or reduce the infusion per protocol and notify the
healthcare provider.
RATIONALE: A significantly elevated aPTT increases the risk of bleeding and requires
adjustment of therapy.
3. Which client should the nurse assess first?
,A. A client with sudden inspiratory stridor after thyroid surgery.
B. A client requesting pain medication.
C. A client awaiting discharge instructions.
D. A client requesting assistance to the restroom.
CORRECT ANSWER: A — A client with sudden inspiratory stridor after thyroid surgery.
RATIONALE: Stridor indicates acute airway obstruction, making it the highest-priority
assessment.
4. A nurse is caring for a client with diabetic ketoacidosis (DKA). Which finding
indicates improvement?
A. Serum bicarbonate increases and blood pH approaches normal.
B. Blood glucose remains above 500 mg/dL.
C. Urine ketones increase.
D. Respiratory rate continues to rise.
CORRECT ANSWER: A — Serum bicarbonate increases and blood pH approaches normal.
RATIONALE: Correction of metabolic acidosis is a key indicator that DKA treatment is
effective.
5. A client develops wheezing, facial swelling, and hypotension immediately after
receiving IV cefazolin. Which action should the nurse take first?
A. Maintain the airway and activate the emergency response.
B. Slow the infusion.
C. Document the reaction.
D. Encourage deep breathing.
CORRECT ANSWER: A — Maintain the airway and activate the emergency response.
RATIONALE: The client is experiencing anaphylaxis, requiring immediate airway management.
6. Which laboratory value requires immediate intervention?
A. Potassium 6.9 mEq/L
B. Sodium 138 mEq/L
, C. Calcium 9.3 mg/dL
D. Magnesium 2.1 mg/dL
CORRECT ANSWER: A — Potassium 6.9 mEq/L
RATIONALE: Severe hyperkalemia can rapidly produce life-threatening cardiac dysrhythmias.
7. A client with heart failure reports increasing shortness of breath when lying
flat. Which term describes this symptom?
A. Orthopnea
B. Syncope
C. Claudication
D. Hemoptysis
CORRECT ANSWER: A — Orthopnea
RATIONALE: Orthopnea is dyspnea that occurs when lying flat due to pulmonary congestion.
8. A client receiving morphine becomes difficult to arouse. Which assessment is
the priority?
A. Respiratory rate and oxygen saturation
B. Bowel sounds
C. Skin turgor
D. Capillary refill
CORRECT ANSWER: A — Respiratory rate and oxygen saturation
RATIONALE: Respiratory depression is the most serious adverse effect of opioid medications.
9. Which intervention best prevents ventilator-associated pneumonia (VAP)?
A. Elevate the head of the bed 30–45 degrees.
B. Keep the client flat.
C. Limit oral care.
D. Increase sedation.
CORRECT ANSWER: A — Elevate the head of the bed 30–45 degrees.