Comprehensive Review | 200 Questions with
Answers and Rationales
A nurse is assessing a patient’s vital signs. Which of the following is the most
accurate method for determining body temperature?
A) Oral thermometer
B) Axillary thermometer
C) Temporal artery thermometer
D) Rectal thermometer
Answer: D) Rectal thermometer
,Rationale: Rectal temperature is considered the most accurate measurement of
body temperature because it is closest to the core temperature.
A nurse is providing discharge teaching to a patient with newly diagnosed
hypertension. Which of the following statements should the nurse include?
A) “You will need to take your blood pressure once a week.”
B) “Dietary changes, such as reducing sodium, can help lower your blood
pressure.”
C) “You can stop your medication when your blood pressure normalizes.”
D) “Hypertension will go away over time with lifestyle changes.”
Answer: B) “Dietary changes, such as reducing sodium, can help lower your blood
pressure.”
Rationale: Sodium reduction is an essential component of managing
hypertension. Discontinuing medication or assuming hypertension will resolve
without medication is incorrect.
A nurse is caring for a patient who has recently undergone surgery. Which of the
following should the nurse monitor to assess for potential complications related
to anesthesia?
A) Blood pressure and heart rate
,B) Respiratory rate and oxygen saturation
C) Urine output and temperature
D) Skin color and pupil response
Answer: B) Respiratory rate and oxygen saturation
Rationale: Post-anesthesia, the primary concern is respiratory depression.
Monitoring respiratory rate and oxygen saturation ensures early detection of
respiratory issues.
The nurse is caring for a 75-year-old patient with a history of heart failure. Which
of the following findings requires immediate action?
A) Weight gain of 1 kg (2.2 lb) in 24 hours
B) Shortness of breath when lying down
C) Bilateral ankle edema
D) Urinary output of 250 mL in 8 hours
Answer: A) Weight gain of 1 kg (2.2 lb) in 24 hours
Rationale: Rapid weight gain can indicate fluid retention, which is a sign of
worsening heart failure and requires immediate intervention.
, A nurse is preparing to administer a medication to a patient who is unconscious.
Which of the following actions is most important before administering the
medication?
A) Verify the patient’s identity using two identifiers.
B) Check the patient’s blood pressure to ensure it is within normal limits.
C) Explain the medication and side effects to the patient.
D) Obtain an order from the healthcare provider.
Answer: A) Verify the patient’s identity using two identifiers.
Rationale: Ensuring correct patient identification is critical to prevent
medication errors, especially when the patient cannot provide consent or
verification.
A nurse is reviewing laboratory results for a patient with liver disease. Which of
the following findings is most likely?
A) Increased hemoglobin level
B) Decreased prothrombin time (PT)
C) Increased bilirubin level