2026/2027
Forms A, B, C & Retakes | 150 Questions with Verified
Answers & Italicized Rationales
SECTION 1: PRIORITIZATION & CLINICAL JUDGMENT (Questions
1–25)
Question 1: A nurse is prioritizing care for four clients. Which client should be seen
first?
A) A client reporting incisional pain 7/10 after surgery
B) A client with COPD reporting mild shortness of breath while eating
C) A client with diabetes and a blood glucose of 48 mg/dL
D) A client scheduled for discharge teaching in 30 minutes
Correct Answer: C
Question 2: A 68-year-old male is 6 hours post–right total knee arthroplasty. He
has a PCA pump with morphine, IV fluids at 75 mL/hr, and a sequential
compression device. Vital signs: BP 142/88, HR 102, RR 10, O2 sat 90% on room
air. He is lethargic and difficult to arouse. Which assessment finding requires
immediate intervention?
A) BP 142/88
B) RR 10 and O2 sat 90%
,C) HR 102
D) Lethargy
Correct Answer: B
Question 3: A nurse in the emergency department is triaging four clients following
a mass casualty event. Which client should the nurse recommend for treatment
first?
A) A client with a closed forearm fracture who is alert and oriented
B) A client with two open chest wounds and left tracheal deviation
C) A client with partial-thickness burns covering 15% of the body
D) A client with a simple laceration that is bleeding slowly
Correct Answer: B
Question 4: A nurse is caring for a client who has a tension pneumothorax. Which
of the following manifestations should the nurse expect?
A) Paradoxical chest movement
B) Bilateral crackles
C) Asymmetry of the chest
D) Blood-tinged sputum
Correct Answer: A
,Question 5: A charge nurse is making shift assignments. Which client should be
assigned to a float nurse from a postpartum unit?
A) A client with new-onset atrial fibrillation
B) A client requiring wound care for a stage 3 pressure ulcer
C) A client with a central line receiving TPN
D) A client with stable vital signs awaiting discharge
Correct Answer: D
Question 6: A nurse on a medical-surgical unit is caring for four clients. Which
client should the nurse see first?
A) A client with a new colostomy who is anxious about pouch changes
B) A client with heart failure who has 3+ pitting edema and reports shortness of breath
C) A client with diabetes who needs insulin before breakfast
D) A client with a wound infection requiring antibiotic administration
Correct Answer: B
, Question 7: A nurse in the intensive care unit is caring for four clients. Which client
should the nurse assess first?
A) A client with a head injury whose Glasgow Coma Scale score dropped from 14 to 11
B) A client with a chest tube who has continuous bubbling in the water seal chamber
C) A client with a central line who is due for a dressing change
D) A client with a nasogastric tube whose output is 200 mL over 4 hours
Correct Answer: A
Question 8: A nurse is assessing a client who is on bed rest and notes one calf is 2.5
cm (1 inch) larger in diameter than the other calf. Which of the following actions
should the nurse take?
A) Place the client's legs in a dependent position
B) Apply a warm, moist soak to the larger calf
C) Massage the larger calf
D) Restrict the client's fluid intake
Correct Answer: A
Question 9: A nurse is caring for a client who is in labor and is receiving oxytocin.
Which of the following findings indicates that the nurse should increase the rate
of infusion?