FITZ Exit Exam Questions and Correct Answers
(Verified Answers) Plus Rationale 2027 Q&A|
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1. A nurse is assessing a client who reports sudden shortness of
breath and chest pain. Which finding requires the nurse's
immediate attention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 96%
C. New onset of cyanosis
D. Temperature of 37.2°C (99°F)
Answer: C. New onset of cyanosis
Rationale: Cyanosis indicates significant hypoxemia and impaired
oxygenation. The nurse should immediately assess airway and
breathing and initiate appropriate interventions. A normal respiratory
rate, normal oxygen saturation, and afebrile temperature do not
indicate the same degree of immediate compromise.
2. Which assessment finding is most characteristic of hypoglycemia?
,A. Warm, dry skin
B. Bradycardia
C. Tremors and diaphoresis
D. Increased thirst
Answer: C. Tremors and diaphoresis
Rationale: Hypoglycemia activates the sympathetic nervous system,
producing manifestations such as tremors, sweating, palpitations,
anxiety, and hunger. Severe hypoglycemia may progress to confusion,
seizures, and loss of consciousness.
3. A client receiving a blood transfusion develops chills, fever, and
low back pain. What should the nurse do first?
A. Slow the transfusion rate
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another set of vital signs
Answer: B. Stop the transfusion
Rationale: Fever, chills, and back pain can indicate an acute hemolytic
transfusion reaction. The nurse should immediately stop the
transfusion and maintain IV access with appropriate compatible fluid
,according to institutional protocol. Further assessment and
notification of the provider follow.
4. Which client should the nurse assess first?
A. A client with chronic arthritis reporting pain of 6/10
B. A postoperative client requesting assistance to the bathroom
C. A client with asthma who has severe wheezing and difficulty
speaking
D. A client awaiting discharge instructions
Answer: C. A client with asthma who has severe wheezing and
difficulty speaking
Rationale: Severe wheezing combined with difficulty speaking
suggests significant respiratory compromise. Airway and breathing
problems take priority over pain, mobility assistance, and discharge
needs.
5. Which intervention is appropriate for a client experiencing a
seizure?
A. Insert an oral airway immediately
B. Restrain the client's extremities
C. Turn the client to the side
D. Give the client oral fluids
, Answer: C. Turn the client to the side
Rationale: Side-lying positioning helps maintain airway patency and
reduces the risk of aspiration. The nurse should protect the client from
injury without restraining the client or placing objects in the mouth.
6. A nurse is caring for a client with heart failure. Which finding
should be reported promptly?
A. Weight gain of 2 kg (4.4 lb) over 2 days
B. Heart rate of 78/min
C. Mild fatigue after activity
D. Blood pressure of 118/72 mm Hg
Answer: A. Weight gain of 2 kg (4.4 lb) over 2 days
Rationale: Rapid weight gain suggests fluid retention and worsening
heart failure. Daily weights are an important indicator of changes in
fluid status. A significant increase over a short period should be
reported and evaluated.
7. Which laboratory value is most important for a nurse to monitor
in a client receiving warfarin therapy?
A. Serum sodium
B. INR
(Verified Answers) Plus Rationale 2027 Q&A|
Instant Download Pdf
1. A nurse is assessing a client who reports sudden shortness of
breath and chest pain. Which finding requires the nurse's
immediate attention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 96%
C. New onset of cyanosis
D. Temperature of 37.2°C (99°F)
Answer: C. New onset of cyanosis
Rationale: Cyanosis indicates significant hypoxemia and impaired
oxygenation. The nurse should immediately assess airway and
breathing and initiate appropriate interventions. A normal respiratory
rate, normal oxygen saturation, and afebrile temperature do not
indicate the same degree of immediate compromise.
2. Which assessment finding is most characteristic of hypoglycemia?
,A. Warm, dry skin
B. Bradycardia
C. Tremors and diaphoresis
D. Increased thirst
Answer: C. Tremors and diaphoresis
Rationale: Hypoglycemia activates the sympathetic nervous system,
producing manifestations such as tremors, sweating, palpitations,
anxiety, and hunger. Severe hypoglycemia may progress to confusion,
seizures, and loss of consciousness.
3. A client receiving a blood transfusion develops chills, fever, and
low back pain. What should the nurse do first?
A. Slow the transfusion rate
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another set of vital signs
Answer: B. Stop the transfusion
Rationale: Fever, chills, and back pain can indicate an acute hemolytic
transfusion reaction. The nurse should immediately stop the
transfusion and maintain IV access with appropriate compatible fluid
,according to institutional protocol. Further assessment and
notification of the provider follow.
4. Which client should the nurse assess first?
A. A client with chronic arthritis reporting pain of 6/10
B. A postoperative client requesting assistance to the bathroom
C. A client with asthma who has severe wheezing and difficulty
speaking
D. A client awaiting discharge instructions
Answer: C. A client with asthma who has severe wheezing and
difficulty speaking
Rationale: Severe wheezing combined with difficulty speaking
suggests significant respiratory compromise. Airway and breathing
problems take priority over pain, mobility assistance, and discharge
needs.
5. Which intervention is appropriate for a client experiencing a
seizure?
A. Insert an oral airway immediately
B. Restrain the client's extremities
C. Turn the client to the side
D. Give the client oral fluids
, Answer: C. Turn the client to the side
Rationale: Side-lying positioning helps maintain airway patency and
reduces the risk of aspiration. The nurse should protect the client from
injury without restraining the client or placing objects in the mouth.
6. A nurse is caring for a client with heart failure. Which finding
should be reported promptly?
A. Weight gain of 2 kg (4.4 lb) over 2 days
B. Heart rate of 78/min
C. Mild fatigue after activity
D. Blood pressure of 118/72 mm Hg
Answer: A. Weight gain of 2 kg (4.4 lb) over 2 days
Rationale: Rapid weight gain suggests fluid retention and worsening
heart failure. Daily weights are an important indicator of changes in
fluid status. A significant increase over a short period should be
reported and evaluated.
7. Which laboratory value is most important for a nurse to monitor
in a client receiving warfarin therapy?
A. Serum sodium
B. INR
