NURSING PROGRAM| FALL READINESS SERIES
ASSESSMENT| JULY 2026 (QUESTIONS And CORRECT
ANSWERS)
1. A client with a history of chronic obstructive pulmonary disease
(COPD) is admitted with acute respiratory distress. Which arterial
blood gas (ABG) finding is most indicative of a COPD exacerbation
complicated by acute respiratory acidosis?
A. pH 7.38, PaCO2 48 mmHg, HCO3- 26 mEq/L
B. pH 7.29, PaCO2 65 mmHg, HCO3- 28 mEq/L
C. pH 7.45, PaCO2 40 mmHg, HCO3- 22 mEq/L
D. pH 7.32, PaCO2 50 mmHg, HCO3- 20 mEq/L
Correct Answer: B
Explanation: A pH below 7.35 (acidemia) combined with an
elevated PaCO2 (>45 mmHg) indicates respiratory acidosis. Option
B shows uncompensated or partially compensated respiratory
acidosis with a low pH and elevated CO2. Option A shows a normal
pH with slightly elevated CO2, indicating compensation. Option C
is normal. Option D shows a low pH and elevated CO2, but the
HCO3- is low, which would be more consistent with a metabolic
acidosis in addition to respiratory acidosis, making it more
complex and less indicative of a simple exacerbation than option B.
2. A nurse is preparing to administer a blood transfusion to a client.
Which of the following actions is most critical to perform
immediately before starting the transfusion?
, A. Verify the client's vital signs.
B. Ensure the client has signed a consent form for the transfusion.
C. Prime the blood administration set with normal saline.
D. Confirm blood type and Rh compatibility with another nurse.
Correct Answer: D
Explanation: The most critical action is verifying the blood product
with another licensed nurse at the client's bedside, checking the
client's identification, blood type, Rh factor, and the unit's
expiration date and number. While the other options are
important steps in the process, ensuring the correct blood is given
to the correct patient is the primary safety measure to prevent a
fatal hemolytic transfusion reaction.
3. A client is receiving IV heparin therapy for a deep vein thrombosis
(DVT). The nurse notes the client’s activated partial
thromboplastin time (aPTT) is 98 seconds. The baseline aPTT is 30
seconds. What is the nurse's priority action?
A. Document the aPTT result in the client's chart.
B. Continue the heparin infusion as prescribed.
C. Notify the healthcare provider to increase the heparin dose.
D. Stop the heparin infusion and prepare to administer protamine
sulfate.
Correct Answer: D
Explanation: The therapeutic range for aPTT on heparin is typically
1.5 to 2.5 times the control value (45-75 seconds for a baseline of
30). An aPTT of 98 seconds is significantly elevated, indicating a
high risk of bleeding. The priority is to stop the infusion to prevent
hemorrhage and prepare the antidote, protamine sulfate. The
, provider should be notified immediately, but stopping the infusion
is the first action.
4. A postoperative client is receiving morphine sulfate via a patient-
controlled analgesia (PCA) pump. The nurse observes the client is
somnolent, has a respiratory rate of 8 breaths/min, and is difficult
to arouse. Which medication should the nurse anticipate
administering?
A. Naloxone
B. Flumazenil
C. Activated charcoal
D. N-acetylcysteine
Correct Answer: A
Explanation: The client is showing signs of opioid toxicity
(somnolence, respiratory depression). Naloxone is a competitive
opioid antagonist used to reverse the effects of morphine and
other opioids. Flumazenil reverses benzodiazepines, activated
charcoal is for GI decontamination, and N-acetylcysteine is the
antidote for acetaminophen toxicity.
5. A client with heart failure is prescribed furosemide. Which of the
following findings would indicate that the medication is having its
desired therapeutic effect?
A. Weight gain of 2 lbs in 24 hours.
B. Clear lung sounds on auscultation.
C. Jugular venous distension (JVD) noted at 45 degrees.
D. Urine output of 30 mL/hour.
, Correct Answer: B
Explanation: Furosemide is a loop diuretic used to reduce fluid
volume overload in heart failure. The desired therapeutic effect is
a reduction in pulmonary congestion, which would be evidenced
by clear lung sounds (resolution of crackles). Weight loss (not
gain), decreased JVD, and adequate urine output are signs of
improvement, but clear lung sounds directly reflect the resolution
of pulmonary edema, a major symptom of heart failure
exacerbation.
6. A nurse is teaching a client with type 2 diabetes mellitus about
self-monitoring of blood glucose (SMBG). Which statement by the
client indicates a need for further teaching?
A. "I will wash my hands with soap and water before testing my
blood sugar."
B. "I will use the side of my fingertip to get a drop of blood."
C. "I will rotate my finger-stick sites to prevent soreness."
D. "I will check my blood sugar before I exercise, and if it's below
100 mg/dL, I will still exercise but keep a fast-acting sugar nearby."
Correct Answer: D
Explanation: The American Diabetes Association generally
recommends that if a client's pre-exercise glucose is below 100
mg/dL, they should ingest a carbohydrate snack (e.g., 15g of
glucose) before exercising to prevent hypoglycemia. Exercising
with a glucose level below 100 mg/dL increases the risk of
hypoglycemia, especially if on insulin or sulfonylureas. The other
options are correct steps for SMBG.
ASSESSMENT| JULY 2026 (QUESTIONS And CORRECT
ANSWERS)
1. A client with a history of chronic obstructive pulmonary disease
(COPD) is admitted with acute respiratory distress. Which arterial
blood gas (ABG) finding is most indicative of a COPD exacerbation
complicated by acute respiratory acidosis?
A. pH 7.38, PaCO2 48 mmHg, HCO3- 26 mEq/L
B. pH 7.29, PaCO2 65 mmHg, HCO3- 28 mEq/L
C. pH 7.45, PaCO2 40 mmHg, HCO3- 22 mEq/L
D. pH 7.32, PaCO2 50 mmHg, HCO3- 20 mEq/L
Correct Answer: B
Explanation: A pH below 7.35 (acidemia) combined with an
elevated PaCO2 (>45 mmHg) indicates respiratory acidosis. Option
B shows uncompensated or partially compensated respiratory
acidosis with a low pH and elevated CO2. Option A shows a normal
pH with slightly elevated CO2, indicating compensation. Option C
is normal. Option D shows a low pH and elevated CO2, but the
HCO3- is low, which would be more consistent with a metabolic
acidosis in addition to respiratory acidosis, making it more
complex and less indicative of a simple exacerbation than option B.
2. A nurse is preparing to administer a blood transfusion to a client.
Which of the following actions is most critical to perform
immediately before starting the transfusion?
, A. Verify the client's vital signs.
B. Ensure the client has signed a consent form for the transfusion.
C. Prime the blood administration set with normal saline.
D. Confirm blood type and Rh compatibility with another nurse.
Correct Answer: D
Explanation: The most critical action is verifying the blood product
with another licensed nurse at the client's bedside, checking the
client's identification, blood type, Rh factor, and the unit's
expiration date and number. While the other options are
important steps in the process, ensuring the correct blood is given
to the correct patient is the primary safety measure to prevent a
fatal hemolytic transfusion reaction.
3. A client is receiving IV heparin therapy for a deep vein thrombosis
(DVT). The nurse notes the client’s activated partial
thromboplastin time (aPTT) is 98 seconds. The baseline aPTT is 30
seconds. What is the nurse's priority action?
A. Document the aPTT result in the client's chart.
B. Continue the heparin infusion as prescribed.
C. Notify the healthcare provider to increase the heparin dose.
D. Stop the heparin infusion and prepare to administer protamine
sulfate.
Correct Answer: D
Explanation: The therapeutic range for aPTT on heparin is typically
1.5 to 2.5 times the control value (45-75 seconds for a baseline of
30). An aPTT of 98 seconds is significantly elevated, indicating a
high risk of bleeding. The priority is to stop the infusion to prevent
hemorrhage and prepare the antidote, protamine sulfate. The
, provider should be notified immediately, but stopping the infusion
is the first action.
4. A postoperative client is receiving morphine sulfate via a patient-
controlled analgesia (PCA) pump. The nurse observes the client is
somnolent, has a respiratory rate of 8 breaths/min, and is difficult
to arouse. Which medication should the nurse anticipate
administering?
A. Naloxone
B. Flumazenil
C. Activated charcoal
D. N-acetylcysteine
Correct Answer: A
Explanation: The client is showing signs of opioid toxicity
(somnolence, respiratory depression). Naloxone is a competitive
opioid antagonist used to reverse the effects of morphine and
other opioids. Flumazenil reverses benzodiazepines, activated
charcoal is for GI decontamination, and N-acetylcysteine is the
antidote for acetaminophen toxicity.
5. A client with heart failure is prescribed furosemide. Which of the
following findings would indicate that the medication is having its
desired therapeutic effect?
A. Weight gain of 2 lbs in 24 hours.
B. Clear lung sounds on auscultation.
C. Jugular venous distension (JVD) noted at 45 degrees.
D. Urine output of 30 mL/hour.
, Correct Answer: B
Explanation: Furosemide is a loop diuretic used to reduce fluid
volume overload in heart failure. The desired therapeutic effect is
a reduction in pulmonary congestion, which would be evidenced
by clear lung sounds (resolution of crackles). Weight loss (not
gain), decreased JVD, and adequate urine output are signs of
improvement, but clear lung sounds directly reflect the resolution
of pulmonary edema, a major symptom of heart failure
exacerbation.
6. A nurse is teaching a client with type 2 diabetes mellitus about
self-monitoring of blood glucose (SMBG). Which statement by the
client indicates a need for further teaching?
A. "I will wash my hands with soap and water before testing my
blood sugar."
B. "I will use the side of my fingertip to get a drop of blood."
C. "I will rotate my finger-stick sites to prevent soreness."
D. "I will check my blood sugar before I exercise, and if it's below
100 mg/dL, I will still exercise but keep a fast-acting sugar nearby."
Correct Answer: D
Explanation: The American Diabetes Association generally
recommends that if a client's pre-exercise glucose is below 100
mg/dL, they should ingest a carbohydrate snack (e.g., 15g of
glucose) before exercising to prevent hypoglycemia. Exercising
with a glucose level below 100 mg/dL increases the risk of
hypoglycemia, especially if on insulin or sulfonylureas. The other
options are correct steps for SMBG.
