1|P a g e SUCCESS!!!
,Question 1
A nurse is caring for a client who has a new prescription for digoxin. Which of the following findings should the
nurse identify as a manifestation of digoxin toxicity?
A. Bradycardia
B. Hyperglycemia
C. Tachycardia
D. Hypotension
Answer: A. Bradycardia
Rationale: Digoxin toxicity can cause bradycardia, nausea, vomiting, visual disturbances (yellow-green halos),
and cardiac dysrhythmias. Digoxin increases the force of myocardial contraction and slows the heart rate;
toxicity exacerbates bradycardia.
Question 2
A nurse is assessing a client who has chronic kidney disease. Which of the following findings should the nurse
expect?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: A. Metabolic acidosis
Rationale: Chronic kidney disease leads to decreased excretion of hydrogen ions and decreased reabsorption of
bicarbonate, resulting in metabolic acidosis (low pH, low bicarbonate).
Question 3
A nurse is preparing to administer an enteral feeding through a nasogastric tube. Which of the following actions
should the nurse take first?
A. Verify tube placement
B. Flush the tube with 30 mL of water
C. Check gastric residual volume
D. Elevate the head of the bed to 30 degrees
Answer: A. Verify tube placement
Rationale: The priority action before administering any enteral feeding is to verify correct tube placement (via x-
ray or pH testing of aspirate) to prevent aspiration and pulmonary complications.
Question 4
2|P a g e SUCCESS!!!
, A nurse is caring for a client who is 2 days post-operative following a total hip arthroplasty. Which of the
following actions is most important to prevent dislocation?
A. Avoid adduction of the affected leg
B. Maintain the affected leg in an extended position
C. Keep the client in a supine position
D. Encourage the client to cross legs at the ankles
Answer: A. Avoid adduction of the affected leg
Rationale: After total hip arthroplasty, the hip is at risk for dislocation. Avoid adduction (crossing legs past
midline), flexion >90°, and internal rotation. Use an abduction pillow to keep legs apart.
Question 5
A nurse is teaching a client who has a new prescription for warfarin. Which of the following statements should
the nurse include?
A. "You should avoid eating foods high in vitamin K."
B. "You can take ibuprofen for pain relief."
C. "Your INR should be checked weekly."
D. "You should take this medication with food."
Answer: A. "You should avoid eating foods high in vitamin K."
Rationale: Warfarin is a vitamin K antagonist. Consistent vitamin K intake is important; sudden changes can
affect INR. Ibuprofen increases bleeding risk. INR monitoring frequency depends on stability.
Question 6
A nurse is assessing a client who has heart failure. Which of the following findings is an early manifestation of
fluid overload?
A. Weight gain of 1 kg (2.2 lb) in 24 hours
B. Decreased urine output
C. Jugular venous distention
D. Peripheral edema
Answer: A. Weight gain of 1 kg (2.2 lb) in 24 hours
Rationale: Daily weight is the most sensitive indicator of fluid status. A weight gain of 1 kg in 24 hours indicates
fluid retention and is often an early sign before visible edema or JVD appears.
Question 7
A nurse is planning care for a client who has a new tracheostomy. Which of the following actions should the
nurse include?
A. Suction the tracheostomy as needed
3|P a g e SUCCESS!!!
,Question 1
A nurse is caring for a client who has a new prescription for digoxin. Which of the following findings should the
nurse identify as a manifestation of digoxin toxicity?
A. Bradycardia
B. Hyperglycemia
C. Tachycardia
D. Hypotension
Answer: A. Bradycardia
Rationale: Digoxin toxicity can cause bradycardia, nausea, vomiting, visual disturbances (yellow-green halos),
and cardiac dysrhythmias. Digoxin increases the force of myocardial contraction and slows the heart rate;
toxicity exacerbates bradycardia.
Question 2
A nurse is assessing a client who has chronic kidney disease. Which of the following findings should the nurse
expect?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: A. Metabolic acidosis
Rationale: Chronic kidney disease leads to decreased excretion of hydrogen ions and decreased reabsorption of
bicarbonate, resulting in metabolic acidosis (low pH, low bicarbonate).
Question 3
A nurse is preparing to administer an enteral feeding through a nasogastric tube. Which of the following actions
should the nurse take first?
A. Verify tube placement
B. Flush the tube with 30 mL of water
C. Check gastric residual volume
D. Elevate the head of the bed to 30 degrees
Answer: A. Verify tube placement
Rationale: The priority action before administering any enteral feeding is to verify correct tube placement (via x-
ray or pH testing of aspirate) to prevent aspiration and pulmonary complications.
Question 4
2|P a g e SUCCESS!!!
, A nurse is caring for a client who is 2 days post-operative following a total hip arthroplasty. Which of the
following actions is most important to prevent dislocation?
A. Avoid adduction of the affected leg
B. Maintain the affected leg in an extended position
C. Keep the client in a supine position
D. Encourage the client to cross legs at the ankles
Answer: A. Avoid adduction of the affected leg
Rationale: After total hip arthroplasty, the hip is at risk for dislocation. Avoid adduction (crossing legs past
midline), flexion >90°, and internal rotation. Use an abduction pillow to keep legs apart.
Question 5
A nurse is teaching a client who has a new prescription for warfarin. Which of the following statements should
the nurse include?
A. "You should avoid eating foods high in vitamin K."
B. "You can take ibuprofen for pain relief."
C. "Your INR should be checked weekly."
D. "You should take this medication with food."
Answer: A. "You should avoid eating foods high in vitamin K."
Rationale: Warfarin is a vitamin K antagonist. Consistent vitamin K intake is important; sudden changes can
affect INR. Ibuprofen increases bleeding risk. INR monitoring frequency depends on stability.
Question 6
A nurse is assessing a client who has heart failure. Which of the following findings is an early manifestation of
fluid overload?
A. Weight gain of 1 kg (2.2 lb) in 24 hours
B. Decreased urine output
C. Jugular venous distention
D. Peripheral edema
Answer: A. Weight gain of 1 kg (2.2 lb) in 24 hours
Rationale: Daily weight is the most sensitive indicator of fluid status. A weight gain of 1 kg in 24 hours indicates
fluid retention and is often an early sign before visible edema or JVD appears.
Question 7
A nurse is planning care for a client who has a new tracheostomy. Which of the following actions should the
nurse include?
A. Suction the tracheostomy as needed
3|P a g e SUCCESS!!!
