Assessment Questions And Correct
Answers (Verified Answers) Plus Rationales
2027 Q&A | Instant Download Pdf
1. A nurse is caring for a client admitted with acute decompensated
heart failure. Which assessment finding requires immediate
intervention?
A. Bilateral ankle edema
B. Weight gain of 2 lb in 24 hours
C. Oxygen saturation of 84% on room air
D. Jugular venous distention
Rationale: An oxygen saturation of 84% indicates significant
hypoxemia requiring immediate intervention to prevent respiratory
failure and tissue hypoxia. Although edema, weight gain, and jugular
venous distention are expected findings in heart failure, they are not
as immediately life-threatening as severe oxygen desaturation. The
,nurse should prioritize airway and breathing according to the ABC
framework.
2. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which oxygen saturation target is most
appropriate?
A. 100%
B. 98%–100%
C. 88%–92%
D. Above 95%
Rationale: Clients with advanced COPD often rely on hypoxic drive for
respiratory stimulation. Maintaining oxygen saturation between 88%
and 92% provides adequate oxygenation while reducing the risk of
suppressing respiratory drive and worsening carbon dioxide retention.
3. Which electrolyte imbalance places a client at greatest risk for life-
threatening cardiac dysrhythmias?
A. Sodium 132 mEq/L
B. Potassium 2.8 mEq/L
C. Calcium 8.7 mg/dL
D. Magnesium 2.0 mg/dL
,Rationale: Severe hypokalemia significantly increases the risk of
ventricular dysrhythmias, muscle weakness, and cardiac arrest.
Potassium is essential for normal cardiac conduction, making this
finding the highest priority.
4. Which assessment finding is most consistent with left-sided heart
failure?
A. Hepatomegaly
B. Peripheral edema
C. Crackles in both lung bases
D. Ascites
Rationale: Left-sided heart failure causes blood to back up into the
pulmonary circulation, resulting in pulmonary edema and crackles.
Peripheral edema, hepatomegaly, and ascites are more commonly
associated with right-sided heart failure.
5. A client receiving intravenous furosemide should be monitored
most closely for which complication?
A. Hyperglycemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
, Rationale: Loop diuretics such as furosemide promote significant
potassium loss through the kidneys, placing clients at risk for
hypokalemia and associated cardiac complications. Frequent
electrolyte monitoring is essential.
6. A nurse suspects sepsis in a hospitalized client. Which finding is
most concerning?
A. Heart rate 88/min
B. Blood pressure 126/76 mm Hg
C. Temperature 102.8°F (39.3°C), heart rate 122/min, and altered
mental status
D. Respiratory rate 18/min
Rationale: Fever, tachycardia, and altered mental status are classic
indicators of systemic infection progressing toward sepsis. Early
recognition and rapid treatment improve survival by preventing septic
shock.
7. Which laboratory value indicates effective anticoagulation therapy
with warfarin?
A. INR 1.0
B. INR 1.4
C. INR 2.5
D. INR 5.8