ADN Exam Questions With Answers and detailed Rationales
Question 1.
A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize?
A. Hyperactive bowel sounds
B. Irregular heart rhythm
C. Increased muscle tone
D. Elevated blood pressure
Correct Answer: B. Irregular heart rhythm
Explanation: Hypokalemia (potassium < 3.5 mEq/L) can cause significant cardiac
dysrhythmias and EKG changes, making cardiac monitoring a priority.
Question 2.
When administering Digoxin to a client with heart failure, which action is most critical for
the nurse to perform first?
A. Monitor the client’s intake and output
B. Check the client’s respiratory rate
C. Review the most recent serum sodium level
D. Assess the apical pulse for one full minute
Correct Answer: D. Assess the apical pulse for one full minute
Explanation: Digoxin is a cardiac glycoside that slows the heart rate. The apical pulse
must be checked for 60 seconds, and the drug held if the rate is below 60 bpm in adults.
Question 3.
A client is prescribed Warfarin for atrial fibrillation. Which laboratory value will the nurse
monitor to evaluate the effectiveness of the therapy?
A. International Normalized Ratio (INR)
B. Platelet count
C. Activated Partial Thromboplastin Time (aPTT)
D. Hemoglobin and Hematocrit
Correct Answer: A. International Normalized Ratio (INR)
Explanation: INR is the standard lab test used to monitor the therapeutic effect of
Warfarin (Coumadin). aPTT is used for Heparin.
, Question 4.
Which of the following findings is most indicative of a tension pneumothorax?
A. Productive cough with rust-colored sputum
B. Bilateral breath sounds with crackles
C. Tracheal deviation toward the unaffected side
D. Flattened neck veins
Correct Answer: C. Tracheal deviation toward the unaffected side
Explanation: Tension pneumothorax causes a shift in the mediastinum, resulting in
tracheal deviation to the opposite (unaffected) side, decreased breath sounds on the
affected side, and distended neck veins.
Question 5.
The nurse is preparing to delegate tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for delegation?
A. Instructing a client on the use of an incentive spirometer
B. Assessing a client’s surgical incision site
C. Administering a PRN oral analgesic
D. Assisting a stable client with ambulation
Correct Answer: D. Assisting a stable client with ambulation
Explanation: UAPs can perform tasks that are routine, non-invasive, and do not require
clinical judgment or assessment, such as assisting a stable client with walking.
Question 6.
A nurse notes a client’s arterial blood gas (ABG) results: pH 7.30, PaCO2 52 mmHg, HCO3
24 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: A. Respiratory Acidosis
Explanation: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the HCO3 is normal, this is uncompensated respiratory acidosis.
Question 1.
A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize?
A. Hyperactive bowel sounds
B. Irregular heart rhythm
C. Increased muscle tone
D. Elevated blood pressure
Correct Answer: B. Irregular heart rhythm
Explanation: Hypokalemia (potassium < 3.5 mEq/L) can cause significant cardiac
dysrhythmias and EKG changes, making cardiac monitoring a priority.
Question 2.
When administering Digoxin to a client with heart failure, which action is most critical for
the nurse to perform first?
A. Monitor the client’s intake and output
B. Check the client’s respiratory rate
C. Review the most recent serum sodium level
D. Assess the apical pulse for one full minute
Correct Answer: D. Assess the apical pulse for one full minute
Explanation: Digoxin is a cardiac glycoside that slows the heart rate. The apical pulse
must be checked for 60 seconds, and the drug held if the rate is below 60 bpm in adults.
Question 3.
A client is prescribed Warfarin for atrial fibrillation. Which laboratory value will the nurse
monitor to evaluate the effectiveness of the therapy?
A. International Normalized Ratio (INR)
B. Platelet count
C. Activated Partial Thromboplastin Time (aPTT)
D. Hemoglobin and Hematocrit
Correct Answer: A. International Normalized Ratio (INR)
Explanation: INR is the standard lab test used to monitor the therapeutic effect of
Warfarin (Coumadin). aPTT is used for Heparin.
, Question 4.
Which of the following findings is most indicative of a tension pneumothorax?
A. Productive cough with rust-colored sputum
B. Bilateral breath sounds with crackles
C. Tracheal deviation toward the unaffected side
D. Flattened neck veins
Correct Answer: C. Tracheal deviation toward the unaffected side
Explanation: Tension pneumothorax causes a shift in the mediastinum, resulting in
tracheal deviation to the opposite (unaffected) side, decreased breath sounds on the
affected side, and distended neck veins.
Question 5.
The nurse is preparing to delegate tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for delegation?
A. Instructing a client on the use of an incentive spirometer
B. Assessing a client’s surgical incision site
C. Administering a PRN oral analgesic
D. Assisting a stable client with ambulation
Correct Answer: D. Assisting a stable client with ambulation
Explanation: UAPs can perform tasks that are routine, non-invasive, and do not require
clinical judgment or assessment, such as assisting a stable client with walking.
Question 6.
A nurse notes a client’s arterial blood gas (ABG) results: pH 7.30, PaCO2 52 mmHg, HCO3
24 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: A. Respiratory Acidosis
Explanation: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the HCO3 is normal, this is uncompensated respiratory acidosis.
