Associate Degree Nursing (ADN) ACTUAL EXAM ALL
QUESTIONS AND ANSWERS ALREADY GRADED A+. 100%
VERIFIED SOLUTIONS | UPDATED PER LATEST
GUIDELINES | GRADED A+
SECTION I — FUNDAMENTALS & CLINICAL JUDGMENT
1. The nurse receives report on four clients. Which client should be assessed FIRST?
A. A client with chronic arthritis reporting pain of 6/10
B. A client with COPD whose oxygen saturation is at the prescribed baseline
C. A client with pneumonia who is newly confused and has a respiratory rate of 32/min
D. A client requesting assistance with toileting
Answer: C
Rationale: New confusion and tachypnea in a client with pneumonia may indicate worsening
hypoxemia or respiratory failure. Airway and breathing take priority over chronic or routine
problems.
2. Which assessment finding requires immediate intervention?
A. Blood pressure 118/72 mm Hg
B. Respiratory rate 7/min after receiving IV morphine
C. Temperature 37.1°C (98.8°F)
D. Heart rate 82/min
Answer: B
Rationale: A respiratory rate of 7/min after opioid administration indicates potentially life-
threatening respiratory depression. The nurse should immediately assess the client and initiate
appropriate interventions.
,3. Which intervention is most effective for preventing healthcare-associated infections?
A. Wearing gloves for every client interaction
B. Performing hand hygiene at appropriate times
C. Administering prophylactic antibiotics
D. Wearing an N95 respirator for every client
Answer: B
Rationale: Proper hand hygiene is one of the most effective methods for preventing
transmission of microorganisms.
4. A nurse realizes that the wrong medication was administered. What should the nurse do
FIRST?
A. Complete an incident report
B. Notify the pharmacy
C. Assess the client
D. Call the client's family
Answer: C
Rationale: The immediate priority is determining whether the client has experienced or is at risk
for harm. Notification and documentation follow assessment and stabilization.
5. Which client statement demonstrates understanding of advance directives?
A. "My family can make every decision even if I am capable."
B. "An advance directive allows me to communicate my healthcare wishes if I cannot speak for
myself."
C. "It allows the nurse to make medical decisions for me."
D. "It is required for every hospital admission."
Answer: B
Rationale: Advance directives communicate a person's healthcare preferences and/or identify a
healthcare decision-maker if the person becomes unable to make decisions.
,6. A client begins having a generalized tonic-clonic seizure. Which action is appropriate?
A. Insert a tongue blade
B. Restrain the client's extremities
C. Protect the client from injury and maintain airway safety
D. Give oral medication
Answer: C
Rationale: During a seizure, the nurse protects the client from injury and maintains airway
safety. Nothing should be placed in the client's mouth and the client should not be restrained.
7. Which client is at greatest risk for pressure injury?
A. Ambulatory young adult
B. Older adult who is immobile and malnourished
C. Independent middle-aged adult
D. Client who walks twice daily
Answer: B
Rationale: Immobility, poor nutrition, decreased tissue perfusion, moisture, and advanced age
increase pressure-injury risk.
8. Which intervention is most appropriate for a client at high risk for falls?
A. Keep the bed at its highest position
B. Place frequently used items within reach
C. Keep all four side rails raised
D. Encourage independent ambulation without assistance
Answer: B
Rationale: Keeping essential items within reach reduces unnecessary attempts to get out of
bed. Fall precautions should also include appropriate footwear, lighting, and assistance.
9. Which documentation is objective?
A. "Client appears anxious."
B. "Client states, 'I feel nervous.'"
, C. "Client is difficult."
D. "Client walked 50 feet using a walker."
Answer: D
Rationale: Objective data are measurable or directly observable. The other statements either
represent subjective information or vague judgments.
10. Which action best promotes client autonomy?
A. Making decisions for the client
B. Providing information and supporting informed choices
C. Limiting choices to one option
D. Asking family members to decide everything
Answer: B
Rationale: Autonomy means respecting the client's right to make informed decisions about
their healthcare.
SECTION II — CARDIOVASCULAR NURSING
11. A client reports crushing substernal chest pain radiating to the jaw. What is the priority
action?
A. Have the client ambulate
B. Assess the client and initiate the acute coronary syndrome protocol
C. Offer a meal
D. Reassess in 1 hour
Answer: B
Rationale: Crushing chest pain with radiation is concerning for acute coronary syndrome. Rapid
assessment and treatment are essential to reduce myocardial injury.
12. Which finding is most consistent with left-sided heart failure?
A. Ascites
B. Pulmonary crackles and dyspnea
QUESTIONS AND ANSWERS ALREADY GRADED A+. 100%
VERIFIED SOLUTIONS | UPDATED PER LATEST
GUIDELINES | GRADED A+
SECTION I — FUNDAMENTALS & CLINICAL JUDGMENT
1. The nurse receives report on four clients. Which client should be assessed FIRST?
A. A client with chronic arthritis reporting pain of 6/10
B. A client with COPD whose oxygen saturation is at the prescribed baseline
C. A client with pneumonia who is newly confused and has a respiratory rate of 32/min
D. A client requesting assistance with toileting
Answer: C
Rationale: New confusion and tachypnea in a client with pneumonia may indicate worsening
hypoxemia or respiratory failure. Airway and breathing take priority over chronic or routine
problems.
2. Which assessment finding requires immediate intervention?
A. Blood pressure 118/72 mm Hg
B. Respiratory rate 7/min after receiving IV morphine
C. Temperature 37.1°C (98.8°F)
D. Heart rate 82/min
Answer: B
Rationale: A respiratory rate of 7/min after opioid administration indicates potentially life-
threatening respiratory depression. The nurse should immediately assess the client and initiate
appropriate interventions.
,3. Which intervention is most effective for preventing healthcare-associated infections?
A. Wearing gloves for every client interaction
B. Performing hand hygiene at appropriate times
C. Administering prophylactic antibiotics
D. Wearing an N95 respirator for every client
Answer: B
Rationale: Proper hand hygiene is one of the most effective methods for preventing
transmission of microorganisms.
4. A nurse realizes that the wrong medication was administered. What should the nurse do
FIRST?
A. Complete an incident report
B. Notify the pharmacy
C. Assess the client
D. Call the client's family
Answer: C
Rationale: The immediate priority is determining whether the client has experienced or is at risk
for harm. Notification and documentation follow assessment and stabilization.
5. Which client statement demonstrates understanding of advance directives?
A. "My family can make every decision even if I am capable."
B. "An advance directive allows me to communicate my healthcare wishes if I cannot speak for
myself."
C. "It allows the nurse to make medical decisions for me."
D. "It is required for every hospital admission."
Answer: B
Rationale: Advance directives communicate a person's healthcare preferences and/or identify a
healthcare decision-maker if the person becomes unable to make decisions.
,6. A client begins having a generalized tonic-clonic seizure. Which action is appropriate?
A. Insert a tongue blade
B. Restrain the client's extremities
C. Protect the client from injury and maintain airway safety
D. Give oral medication
Answer: C
Rationale: During a seizure, the nurse protects the client from injury and maintains airway
safety. Nothing should be placed in the client's mouth and the client should not be restrained.
7. Which client is at greatest risk for pressure injury?
A. Ambulatory young adult
B. Older adult who is immobile and malnourished
C. Independent middle-aged adult
D. Client who walks twice daily
Answer: B
Rationale: Immobility, poor nutrition, decreased tissue perfusion, moisture, and advanced age
increase pressure-injury risk.
8. Which intervention is most appropriate for a client at high risk for falls?
A. Keep the bed at its highest position
B. Place frequently used items within reach
C. Keep all four side rails raised
D. Encourage independent ambulation without assistance
Answer: B
Rationale: Keeping essential items within reach reduces unnecessary attempts to get out of
bed. Fall precautions should also include appropriate footwear, lighting, and assistance.
9. Which documentation is objective?
A. "Client appears anxious."
B. "Client states, 'I feel nervous.'"
, C. "Client is difficult."
D. "Client walked 50 feet using a walker."
Answer: D
Rationale: Objective data are measurable or directly observable. The other statements either
represent subjective information or vague judgments.
10. Which action best promotes client autonomy?
A. Making decisions for the client
B. Providing information and supporting informed choices
C. Limiting choices to one option
D. Asking family members to decide everything
Answer: B
Rationale: Autonomy means respecting the client's right to make informed decisions about
their healthcare.
SECTION II — CARDIOVASCULAR NURSING
11. A client reports crushing substernal chest pain radiating to the jaw. What is the priority
action?
A. Have the client ambulate
B. Assess the client and initiate the acute coronary syndrome protocol
C. Offer a meal
D. Reassess in 1 hour
Answer: B
Rationale: Crushing chest pain with radiation is concerning for acute coronary syndrome. Rapid
assessment and treatment are essential to reduce myocardial injury.
12. Which finding is most consistent with left-sided heart failure?
A. Ascites
B. Pulmonary crackles and dyspnea
