ADN Exam Questions With Answers and detailed Rationales
Question 1.
A nurse is assessing a client who has a chest tube connected to a suction drainage system.
Which of the following findings should the nurse report to the provider?
A. Firmly taped connections between the tube and the drainage system
B. Fluctuation of the water level with respiration
C. Presence of 50 mL of serous drainage in 4 hours
D. Constant bubbling in the water seal chamber
Correct Answer: D. Constant bubbling in the water seal chamber
Explanation: Constant bubbling in the water seal chamber indicates an air leak in the
system, which must be addressed. Tidaling (fluctuation) is normal, and 50 mL of drainage
over 4 hours is within expected limits.
Question 2.
A client is prescribed lisinopril for hypertension. Which of the following adverse effects
should the nurse instruct the client to report immediately?
A. Swelling of the tongue or lips
B. Occasional dry cough
C. Mild dizziness upon standing
D. Increased urination
Correct Answer: A. Swelling of the tongue or lips
Explanation: Swelling of the tongue or lips indicates angioedema, a life-threatening
adverse effect of ACE inhibitors. While a dry cough is common, angioedema requires
immediate intervention.
Question 3.
A nurse is caring for a client with a history of alcohol use disorder who is experiencing
tremors and agitation. Which medication should the nurse expect to administer?
A. Methadone
B. Disulfiram
C. Varenicline
D. Chlordiazepoxide
Correct Answer: D. Chlordiazepoxide
Explanation: Chlordiazepoxide is a benzodiazepine used to prevent or treat symptoms of
acute alcohol withdrawal, including tremors and agitation.
, Question 4.
A nurse is reviewing the laboratory results of a client receiving heparin via continuous IV
infusion. The aPTT is 90 seconds (control 30 seconds). Which action should the nurse take?
A. Stop the infusion and notify the provider
B. Increase the infusion rate
C. Continue the infusion at the current rate
D. Administer vitamin K intramuscularly
Correct Answer: A. Stop the infusion and notify the provider
Explanation: An aPTT of 90 seconds is significantly above the therapeutic range (usually
1.5 to 2.5 times the control, which would be 45-75 seconds). The infusion should be
stopped to prevent bleeding.
Question 5.
Which of the following findings is a late sign of increased intracranial pressure (ICP)?
A. Restlessness and irritability
B. Increased heart rate
C. Dilated and fixed pupils
D. Headache described as ‘worst in my life’
Correct Answer: C. Dilated and fixed pupils
Explanation: Dilated and fixed pupils are a late sign of increased ICP indicating
herniation. Restlessness is an early sign. Cushing’s Triad (bradycardia, widened pulse
pressure) is also a late sign.
Question 6.
A nurse is assessing a client with Cushing’s syndrome. Which of the following findings
should the nurse expect?
A. Weight loss and hypotension
B. Bronze skin pigmentation
C. Hyperkalemia and hyponatremia
D. Truncal obesity and moon face
Correct Answer: D. Truncal obesity and moon face
Explanation: Cushing’s syndrome is characterized by excess cortisol, leading to fat
redistribution (truncal obesity, buffalo hump, moon face). Bronze skin is characteristic of
Addison’s disease.
Question 1.
A nurse is assessing a client who has a chest tube connected to a suction drainage system.
Which of the following findings should the nurse report to the provider?
A. Firmly taped connections between the tube and the drainage system
B. Fluctuation of the water level with respiration
C. Presence of 50 mL of serous drainage in 4 hours
D. Constant bubbling in the water seal chamber
Correct Answer: D. Constant bubbling in the water seal chamber
Explanation: Constant bubbling in the water seal chamber indicates an air leak in the
system, which must be addressed. Tidaling (fluctuation) is normal, and 50 mL of drainage
over 4 hours is within expected limits.
Question 2.
A client is prescribed lisinopril for hypertension. Which of the following adverse effects
should the nurse instruct the client to report immediately?
A. Swelling of the tongue or lips
B. Occasional dry cough
C. Mild dizziness upon standing
D. Increased urination
Correct Answer: A. Swelling of the tongue or lips
Explanation: Swelling of the tongue or lips indicates angioedema, a life-threatening
adverse effect of ACE inhibitors. While a dry cough is common, angioedema requires
immediate intervention.
Question 3.
A nurse is caring for a client with a history of alcohol use disorder who is experiencing
tremors and agitation. Which medication should the nurse expect to administer?
A. Methadone
B. Disulfiram
C. Varenicline
D. Chlordiazepoxide
Correct Answer: D. Chlordiazepoxide
Explanation: Chlordiazepoxide is a benzodiazepine used to prevent or treat symptoms of
acute alcohol withdrawal, including tremors and agitation.
, Question 4.
A nurse is reviewing the laboratory results of a client receiving heparin via continuous IV
infusion. The aPTT is 90 seconds (control 30 seconds). Which action should the nurse take?
A. Stop the infusion and notify the provider
B. Increase the infusion rate
C. Continue the infusion at the current rate
D. Administer vitamin K intramuscularly
Correct Answer: A. Stop the infusion and notify the provider
Explanation: An aPTT of 90 seconds is significantly above the therapeutic range (usually
1.5 to 2.5 times the control, which would be 45-75 seconds). The infusion should be
stopped to prevent bleeding.
Question 5.
Which of the following findings is a late sign of increased intracranial pressure (ICP)?
A. Restlessness and irritability
B. Increased heart rate
C. Dilated and fixed pupils
D. Headache described as ‘worst in my life’
Correct Answer: C. Dilated and fixed pupils
Explanation: Dilated and fixed pupils are a late sign of increased ICP indicating
herniation. Restlessness is an early sign. Cushing’s Triad (bradycardia, widened pulse
pressure) is also a late sign.
Question 6.
A nurse is assessing a client with Cushing’s syndrome. Which of the following findings
should the nurse expect?
A. Weight loss and hypotension
B. Bronze skin pigmentation
C. Hyperkalemia and hyponatremia
D. Truncal obesity and moon face
Correct Answer: D. Truncal obesity and moon face
Explanation: Cushing’s syndrome is characterized by excess cortisol, leading to fat
redistribution (truncal obesity, buffalo hump, moon face). Bronze skin is characteristic of
Addison’s disease.
