Comprehensive Assessment 2026 B |
Practice Questions, Answers &
Rationales Guaranteed Pass (GRADED
A+)
Question 1
A nurse is assessing a client who has heart failure. Which
finding should the nurse recognize as an indication of worsening
fluid retention?
A. Weight loss of 1 kg (2.2 lb) over 1 week
B. Urine output of 1,500 mL/day
C. Bilateral ankle edema
D. Heart rate of 68/min
Answer: _C. Bilateral ankle edema_
Rationale: Peripheral edema is a common manifestation of fluid
retention associated with worsening heart failure. Daily weights
and assessment for edema help monitor changes in fluid status.
Question 2
A nurse is caring for a client receiving digoxin. Which finding
requires the nurse to withhold the medication and notify the
provider?
,A. Apical pulse of 54/min
B. Blood pressure of 128/76 mm Hg
C. Respiratory rate of 18/min
D. Temperature of 37°C (98.6°F)
Answer: _A. Apical pulse of 54/min_
Rationale: Digoxin can cause bradycardia. The nurse should
assess the apical pulse before administration and generally
withhold the medication for significant bradycardia according
to the prescribed parameters.
Question 3
A nurse is caring for a client who has COPD and is receiving
oxygen. Which oxygen delivery method is appropriate when a
precise concentration of oxygen is required?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial-rebreather mask
Answer: _B. Venturi mask_
Rationale: A Venturi mask delivers a controlled and precise
oxygen concentration and is particularly useful for clients with
COPD who require carefully regulated oxygen therapy.
Question 4
,A client with diabetes mellitus is experiencing diaphoresis,
tremors, and confusion. Which action should the nurse take
first?
A. Administer the client's scheduled insulin.
B. Check the client's blood glucose level.
C. Encourage the client to ambulate.
D. Administer a high-protein meal.
Answer: _B. Check the client's blood glucose level._
Rationale: Diaphoresis, tremors, and confusion are
manifestations of hypoglycemia. The nurse should immediately
assess the blood glucose level and provide rapid treatment if
hypoglycemia is confirmed.
Question 5
A nurse is teaching a client who has a new prescription for
warfarin. Which statement by the client indicates an
understanding of the teaching?
A. "I will take aspirin for headaches without contacting my
provider."
B. "I will keep my intake of foods containing vitamin K
consistent."
C. "I can stop taking the medication once I feel better."
D. "I should double my dose if I miss one."
Answer: _B. "I will keep my intake of foods containing vitamin
K consistent."_
, Rationale: Vitamin K can reduce the anticoagulant effect of
warfarin. Clients should maintain a consistent intake of vitamin
K rather than eliminating these foods completely.
Question 6
A nurse is assessing a client who has a suspected stroke. Which
finding is most concerning?
A. Sudden unilateral weakness
B. Gradual onset of fatigue
C. Mild bilateral ankle edema
D. Increased appetite
Answer: _A. Sudden unilateral weakness_
Rationale: Sudden unilateral weakness is a classic manifestation
of an acute stroke and requires immediate evaluation and
intervention.
Question 7
A nurse is caring for a client who has pneumonia. Which finding
indicates improvement?
A. Respiratory rate of 28/min
B. Oxygen saturation of 89%
C. Decreased crackles on auscultation
D. Increasing temperature