PN 2002 FINAL EXAMINATION COMPREHENSIVE EXAM
QUESTIONS AND DETAILED RATIONALES LATEST UPDATE
1. A practical nursing student is assessing a patient who suddenly
develops shortness of breath, chest discomfort, and anxiety after
prolonged immobility. Which finding requires immediate
intervention?
A. Mild bilateral ankle edema
B. Sudden pleuritic chest pain and tachypnea
C. Decreased appetite for two days
D. Occasional nonproductive cough
Correct Answer: B
Rationale: Sudden pleuritic chest pain and tachypnea following
immobility are concerning for pulmonary embolism, which requires
immediate assessment and intervention.
2. A nurse is preparing to administer medication to an adult patient.
Which action best demonstrates safe medication administration
practice?
A. Administering medication before checking the patient's identification
B. Comparing the medication label with the prescription only once
C. Verifying the medication using appropriate identification and safety
checks
D. Asking another patient whether the medication belongs to them
Correct Answer: C
Rationale: Verifying the medication using appropriate identification and
safety checks (the rights of medication administration) is the standard
of practice to prevent errors.
,3. A nurse is caring for a client with a new colostomy. Which stoma
assessment finding should the nurse report to the provider
immediately?
A. Pink, moist stoma
B. Dusky, cyanotic stoma
C. Slight edema around the stoma
D. Small amount of serosanguineous drainage
Correct Answer: B
Rationale: A dusky or cyanotic stoma indicates compromised blood flow
and possible necrosis, requiring immediate intervention.
4. A nurse is reinforcing teaching with a client who has heart failure
and a new prescription for furosemide. Which statement by the client
indicates an understanding of the teaching?
A. "I will eat foods high in potassium, like bananas."
B. "I will take this medication at bedtime."
C. "I will restrict my fluid intake to 1 liter per day."
D. "I will monitor my weight weekly."
Correct Answer: A
Rationale: Furosemide is a loop diuretic that depletes potassium; clients
should consume potassium-rich foods unless contraindicated.
5. A nurse is assessing a client who is 2 days postoperative following a
cesarean birth. Which finding should the nurse report?
A. Temperature of 100.4 F (38 C)
B. Fundus firm at the umbilicus
C. Reddish-brown lochia
D. Incisional pain rated 4/10
Correct Answer: A
,Rationale: A temperature of 100.4 F or higher after the first 24 hours
postpartum may indicate infection and should be reported.
6. A nurse is caring for a pediatric client with suspected epiglottitis.
Which action is contraindicated?
A. Keeping the child calm
B. Inspecting the throat with a tongue blade
C. Administering prescribed antibiotics
D. Providing humidified oxygen
Correct Answer: B
Rationale: Inspecting the throat with a tongue blade can trigger
laryngospasm and complete airway obstruction in a child with
epiglottitis.
7. A nurse is delegating tasks to unlicensed assistive personnel (UAP).
Which task is appropriate to delegate?
A. Administering oral medications
B. Assessing a client's pain level
C. Measuring and recording vital signs
D. Teaching a client about a new diet
Correct Answer: C
Rationale: Measuring and recording vital signs for stable clients is within
the scope of practice for UAP.
8. A nurse is caring for a client experiencing acute alcohol withdrawal.
Which medication should the nurse anticipate administering?
A. Lorazepam
B. Fluoxetine
C. Haloperidol
D. Naltrexone
, Correct Answer: A
Rationale: Benzodiazepines like lorazepam are the first-line treatment
for managing acute alcohol withdrawal symptoms and preventing
seizures.
9. A nurse is teaching a client about a low-sodium diet. Which food
should the client be instructed to avoid?
A. Fresh apples
B. Canned soup
C. Plain chicken breast
D. Brown rice
Correct Answer: B
Rationale: Canned soups are highly processed and contain large
amounts of sodium as a preservative.
10. A nurse is assessing a client with diabetes mellitus who reports
feeling shaky, sweaty, and hungry. Which action should the nurse take
first?
A. Administer insulin
B. Check the client's blood glucose level
C. Provide a glass of orange juice
D. Notify the provider
Correct Answer: B
Rationale: The nurse should first verify the blood glucose level to
confirm hypoglycemia before administering treatment.
11. A nurse is monitoring a client receiving a blood transfusion. Which
finding indicates a hemolytic reaction?
A. Urticaria and itching
B. Fever and chills
QUESTIONS AND DETAILED RATIONALES LATEST UPDATE
1. A practical nursing student is assessing a patient who suddenly
develops shortness of breath, chest discomfort, and anxiety after
prolonged immobility. Which finding requires immediate
intervention?
A. Mild bilateral ankle edema
B. Sudden pleuritic chest pain and tachypnea
C. Decreased appetite for two days
D. Occasional nonproductive cough
Correct Answer: B
Rationale: Sudden pleuritic chest pain and tachypnea following
immobility are concerning for pulmonary embolism, which requires
immediate assessment and intervention.
2. A nurse is preparing to administer medication to an adult patient.
Which action best demonstrates safe medication administration
practice?
A. Administering medication before checking the patient's identification
B. Comparing the medication label with the prescription only once
C. Verifying the medication using appropriate identification and safety
checks
D. Asking another patient whether the medication belongs to them
Correct Answer: C
Rationale: Verifying the medication using appropriate identification and
safety checks (the rights of medication administration) is the standard
of practice to prevent errors.
,3. A nurse is caring for a client with a new colostomy. Which stoma
assessment finding should the nurse report to the provider
immediately?
A. Pink, moist stoma
B. Dusky, cyanotic stoma
C. Slight edema around the stoma
D. Small amount of serosanguineous drainage
Correct Answer: B
Rationale: A dusky or cyanotic stoma indicates compromised blood flow
and possible necrosis, requiring immediate intervention.
4. A nurse is reinforcing teaching with a client who has heart failure
and a new prescription for furosemide. Which statement by the client
indicates an understanding of the teaching?
A. "I will eat foods high in potassium, like bananas."
B. "I will take this medication at bedtime."
C. "I will restrict my fluid intake to 1 liter per day."
D. "I will monitor my weight weekly."
Correct Answer: A
Rationale: Furosemide is a loop diuretic that depletes potassium; clients
should consume potassium-rich foods unless contraindicated.
5. A nurse is assessing a client who is 2 days postoperative following a
cesarean birth. Which finding should the nurse report?
A. Temperature of 100.4 F (38 C)
B. Fundus firm at the umbilicus
C. Reddish-brown lochia
D. Incisional pain rated 4/10
Correct Answer: A
,Rationale: A temperature of 100.4 F or higher after the first 24 hours
postpartum may indicate infection and should be reported.
6. A nurse is caring for a pediatric client with suspected epiglottitis.
Which action is contraindicated?
A. Keeping the child calm
B. Inspecting the throat with a tongue blade
C. Administering prescribed antibiotics
D. Providing humidified oxygen
Correct Answer: B
Rationale: Inspecting the throat with a tongue blade can trigger
laryngospasm and complete airway obstruction in a child with
epiglottitis.
7. A nurse is delegating tasks to unlicensed assistive personnel (UAP).
Which task is appropriate to delegate?
A. Administering oral medications
B. Assessing a client's pain level
C. Measuring and recording vital signs
D. Teaching a client about a new diet
Correct Answer: C
Rationale: Measuring and recording vital signs for stable clients is within
the scope of practice for UAP.
8. A nurse is caring for a client experiencing acute alcohol withdrawal.
Which medication should the nurse anticipate administering?
A. Lorazepam
B. Fluoxetine
C. Haloperidol
D. Naltrexone
, Correct Answer: A
Rationale: Benzodiazepines like lorazepam are the first-line treatment
for managing acute alcohol withdrawal symptoms and preventing
seizures.
9. A nurse is teaching a client about a low-sodium diet. Which food
should the client be instructed to avoid?
A. Fresh apples
B. Canned soup
C. Plain chicken breast
D. Brown rice
Correct Answer: B
Rationale: Canned soups are highly processed and contain large
amounts of sodium as a preservative.
10. A nurse is assessing a client with diabetes mellitus who reports
feeling shaky, sweaty, and hungry. Which action should the nurse take
first?
A. Administer insulin
B. Check the client's blood glucose level
C. Provide a glass of orange juice
D. Notify the provider
Correct Answer: B
Rationale: The nurse should first verify the blood glucose level to
confirm hypoglycemia before administering treatment.
11. A nurse is monitoring a client receiving a blood transfusion. Which
finding indicates a hemolytic reaction?
A. Urticaria and itching
B. Fever and chills
