NURS 110 – Midterm Questions And
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
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1. A client presents with a blood pressure of 148/92 mmHg, a heart rate of 88
bpm, and reports occasional headaches. The client's laboratory results
show a serum sodium of 142 mEq/L and potassium of 3.8 mEq/L. Based on
this data, the nurse should prioritize which initial intervention?
A. Administer a potassium supplement as prescribed.
B. Recheck the blood pressure in the contralateral arm.
C. Instruct the client on a low-sodium diet.
D. Prepare the client for an electrocardiogram.
Answer: B
Rationale: The initial priority when an elevated blood pressure is noted is
to verify the accuracy of the measurement. Rechecking the blood pressure
in the contralateral arm ensures the reading is not an artifact. While diet
and ECG may be indicated later, verification of the vital sign is the
immediate first step.
2. The nurse is assessing a client who is 24 hours post-operative from an
abdominal hysterectomy. The client's oxygen saturation is 91% on room air,
respiratory rate is 24 breaths/min, and they report pain of 6 out of 10 at the
incision site. Which of the following nursing actions is the priority?
A. Administer the prescribed PRN analgesic.
B. Encourage the client to use the incentive spirometer.
C. Notify the healthcare provider of the oxygen saturation.
D. Apply a pulse oximeter to a different finger.
Answer: B
Rationale: The priority is to address the low oxygen saturation and
, tachypnea, which are likely due to hypoventilation from pain and
anesthesia. Encouraging the use of the incentive spirometer promotes
deep breathing and lung expansion, which directly addresses the
underlying cause of the low SpO2. Pain management is important but is
an intervention to facilitate the breathing exercise.
3. In the context of the "Quality and Safety Education for Nurses" (QSEN)
initiative, a nurse who integrates the best current evidence with clinical
expertise and patient values to deliver optimal care is demonstrating
competency in which area?
A. Patient-Centered Care
B. Teamwork and Collaboration
C. Evidence-Based Practice
D. Quality Improvement
Answer: C
Rationale: Evidence-Based Practice (EBP) is explicitly defined as the
integration of best current evidence, clinical expertise, and patient/family
preferences and values. This is the core definition of EBP within the QSEN
framework. Patient-Centered Care focuses on the patient's values and
preferences as a central component, but it does not encompass the
systematic use of evidence and clinical expertise.
4. A client with a history of diabetes mellitus type 2 is admitted with
pneumonia. The nurse notes that the client's blood glucose levels have
been consistently elevated despite receiving their usual dose of metformin.
What is the most likely physiological explanation for this hyperglycemia?
A. The infection is causing a reduction in the renal clearance of metformin.
B. The client has been non-adherent with their diabetic diet due to a poor
appetite.
C. The stress response from the infection is leading to increased cortisol and
glucagon release.
D. The pneumonia has caused a systemic inflammatory response that
destroyed pancreatic beta cells.
Answer: C
, Rationale: During acute illness and infection, the body releases stress
hormones like cortisol and glucagon. These hormones promote
gluconeogenesis and glycogenolysis, leading to increased blood glucose
levels. This is a classic physiological response to stress, often termed
"stress hyperglycemia," and is the most likely cause in a type 2 diabetic.
This is a common concept on nursing exams regarding infection and
glucose metabolism.
5. A nurse is preparing to administer a medication via a nasogastric (NG) tube.
Which of the following actions is correct for this procedure?
A. Crush all enteric-coated tablets to ensure they pass through the tube.
B. Use a syringe with a catheter tip to administer the medication.
C. Flush the tube with 30 mL of sterile water before and after each
medication.
D. Mix all crushed medications together to minimize the number of flushes.
Answer: C
Rationale: Flushing the NG tube with 30 mL of water before and after
medication administration is a standard practice to prevent clogging and
ensure the medication is delivered to the stomach. Enteric-coated tablets
should never be crushed. A Luer-Lok or catheter tip syringe is not
standard; a slip-tip syringe is preferred to avoid pressure injury. Mixing
medications can cause incompatibilities and precipitates.
6. The nurse is performing a head-to-toe assessment on a newly admitted
client. When auscultating the client's lungs, the nurse hears a high-pitched,
musical sound during expiration. The nurse should document this finding as:
A. Crackles
B. Rhonchi
C. Stridor
D. Wheezes
Answer: D
Rationale: Wheezes are continuous, high-pitched, musical sounds that are
most commonly heard during expiration. They are caused by air passing
through narrowed or constricted airways, such as in asthma or COPD.
, Crackles are discontinuous, crackling sounds. Rhonchi are low-pitched,
snoring sounds. Stridor is a high-pitched sound heard primarily on
inspiration, indicating upper airway obstruction.
7. A client is admitted with dehydration and hyponatremia (serum sodium of
128 mEq/L). Which of the following clinical manifestations would the nurse
expect to observe?
A. Thirst and dry mucous membranes.
B. Muscle cramps and hyperactive bowel sounds.
C. Confusion and muscle weakness.
D. Bounding peripheral pulses and jugular venous distention.
Answer: C
Rationale: Hyponatremia (low sodium) causes water to move into the
brain cells, leading to cerebral edema. The primary manifestations are
neurological, such as confusion, lethargy, headache, and muscle
weakness. Severe cases can lead to seizures and coma. Thirst is a
symptom of hypernatremia. Bounding pulses are associated with fluid
volume overload.
8. A nurse is providing discharge teaching to a client prescribed warfarin
(Coumadin). Which of the following statements made by the client indicates
a correct understanding of the medication?
A. "I will need to have my blood drawn regularly to check my INR level."
B. "I can take ibuprofen for my headaches if my INR is stable."
C. "I should increase my intake of green leafy vegetables like spinach."
D. "I will stop taking the medication if I notice any bruising."
Answer: A
Rationale: Warfarin therapy requires regular monitoring of the
International Normalized Ratio (INR) to ensure the medication is within a
therapeutic and safe range. Ibuprofen increases bleeding risk and should
be avoided. A consistent intake of vitamin K (found in leafy greens) is
important, not an increase. Bruising is a common side effect, and the
medication should not be stopped abruptly without consulting a
healthcare provider.
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. A client presents with a blood pressure of 148/92 mmHg, a heart rate of 88
bpm, and reports occasional headaches. The client's laboratory results
show a serum sodium of 142 mEq/L and potassium of 3.8 mEq/L. Based on
this data, the nurse should prioritize which initial intervention?
A. Administer a potassium supplement as prescribed.
B. Recheck the blood pressure in the contralateral arm.
C. Instruct the client on a low-sodium diet.
D. Prepare the client for an electrocardiogram.
Answer: B
Rationale: The initial priority when an elevated blood pressure is noted is
to verify the accuracy of the measurement. Rechecking the blood pressure
in the contralateral arm ensures the reading is not an artifact. While diet
and ECG may be indicated later, verification of the vital sign is the
immediate first step.
2. The nurse is assessing a client who is 24 hours post-operative from an
abdominal hysterectomy. The client's oxygen saturation is 91% on room air,
respiratory rate is 24 breaths/min, and they report pain of 6 out of 10 at the
incision site. Which of the following nursing actions is the priority?
A. Administer the prescribed PRN analgesic.
B. Encourage the client to use the incentive spirometer.
C. Notify the healthcare provider of the oxygen saturation.
D. Apply a pulse oximeter to a different finger.
Answer: B
Rationale: The priority is to address the low oxygen saturation and
, tachypnea, which are likely due to hypoventilation from pain and
anesthesia. Encouraging the use of the incentive spirometer promotes
deep breathing and lung expansion, which directly addresses the
underlying cause of the low SpO2. Pain management is important but is
an intervention to facilitate the breathing exercise.
3. In the context of the "Quality and Safety Education for Nurses" (QSEN)
initiative, a nurse who integrates the best current evidence with clinical
expertise and patient values to deliver optimal care is demonstrating
competency in which area?
A. Patient-Centered Care
B. Teamwork and Collaboration
C. Evidence-Based Practice
D. Quality Improvement
Answer: C
Rationale: Evidence-Based Practice (EBP) is explicitly defined as the
integration of best current evidence, clinical expertise, and patient/family
preferences and values. This is the core definition of EBP within the QSEN
framework. Patient-Centered Care focuses on the patient's values and
preferences as a central component, but it does not encompass the
systematic use of evidence and clinical expertise.
4. A client with a history of diabetes mellitus type 2 is admitted with
pneumonia. The nurse notes that the client's blood glucose levels have
been consistently elevated despite receiving their usual dose of metformin.
What is the most likely physiological explanation for this hyperglycemia?
A. The infection is causing a reduction in the renal clearance of metformin.
B. The client has been non-adherent with their diabetic diet due to a poor
appetite.
C. The stress response from the infection is leading to increased cortisol and
glucagon release.
D. The pneumonia has caused a systemic inflammatory response that
destroyed pancreatic beta cells.
Answer: C
, Rationale: During acute illness and infection, the body releases stress
hormones like cortisol and glucagon. These hormones promote
gluconeogenesis and glycogenolysis, leading to increased blood glucose
levels. This is a classic physiological response to stress, often termed
"stress hyperglycemia," and is the most likely cause in a type 2 diabetic.
This is a common concept on nursing exams regarding infection and
glucose metabolism.
5. A nurse is preparing to administer a medication via a nasogastric (NG) tube.
Which of the following actions is correct for this procedure?
A. Crush all enteric-coated tablets to ensure they pass through the tube.
B. Use a syringe with a catheter tip to administer the medication.
C. Flush the tube with 30 mL of sterile water before and after each
medication.
D. Mix all crushed medications together to minimize the number of flushes.
Answer: C
Rationale: Flushing the NG tube with 30 mL of water before and after
medication administration is a standard practice to prevent clogging and
ensure the medication is delivered to the stomach. Enteric-coated tablets
should never be crushed. A Luer-Lok or catheter tip syringe is not
standard; a slip-tip syringe is preferred to avoid pressure injury. Mixing
medications can cause incompatibilities and precipitates.
6. The nurse is performing a head-to-toe assessment on a newly admitted
client. When auscultating the client's lungs, the nurse hears a high-pitched,
musical sound during expiration. The nurse should document this finding as:
A. Crackles
B. Rhonchi
C. Stridor
D. Wheezes
Answer: D
Rationale: Wheezes are continuous, high-pitched, musical sounds that are
most commonly heard during expiration. They are caused by air passing
through narrowed or constricted airways, such as in asthma or COPD.
, Crackles are discontinuous, crackling sounds. Rhonchi are low-pitched,
snoring sounds. Stridor is a high-pitched sound heard primarily on
inspiration, indicating upper airway obstruction.
7. A client is admitted with dehydration and hyponatremia (serum sodium of
128 mEq/L). Which of the following clinical manifestations would the nurse
expect to observe?
A. Thirst and dry mucous membranes.
B. Muscle cramps and hyperactive bowel sounds.
C. Confusion and muscle weakness.
D. Bounding peripheral pulses and jugular venous distention.
Answer: C
Rationale: Hyponatremia (low sodium) causes water to move into the
brain cells, leading to cerebral edema. The primary manifestations are
neurological, such as confusion, lethargy, headache, and muscle
weakness. Severe cases can lead to seizures and coma. Thirst is a
symptom of hypernatremia. Bounding pulses are associated with fluid
volume overload.
8. A nurse is providing discharge teaching to a client prescribed warfarin
(Coumadin). Which of the following statements made by the client indicates
a correct understanding of the medication?
A. "I will need to have my blood drawn regularly to check my INR level."
B. "I can take ibuprofen for my headaches if my INR is stable."
C. "I should increase my intake of green leafy vegetables like spinach."
D. "I will stop taking the medication if I notice any bruising."
Answer: A
Rationale: Warfarin therapy requires regular monitoring of the
International Normalized Ratio (INR) to ensure the medication is within a
therapeutic and safe range. Ibuprofen increases bleeding risk and should
be avoided. A consistent intake of vitamin K (found in leafy greens) is
important, not an increase. Bruising is a common side effect, and the
medication should not be stopped abruptly without consulting a
healthcare provider.
