VERIFIED AND WELL GRADED 2025/2026
1. Which of the following is the priority assessment for a client with congestive
heart failure?
A. Skin turgor
B. Lung sounds
C. Capillary refill
D. Bowel sounds
Correct Answer: B. Lung sounds
Rationale: Assessing lung sounds is critical to identify fluid overload and
pulmonary edema, which are life-threatening complications of CHF.
2. A client with diabetes mellitus is experiencing hypoglycemia. Which of the
following is the immediate intervention?
A. Administer insulin
B. Provide 15 g of fast-acting carbohydrate
C. Encourage rest
D. Administer glucagon orally
Correct Answer: B. Provide 15 g of fast-acting carbohydrate
Rationale: Rapid administration of carbohydrate helps raise blood glucose levels
quickly in hypoglycemia.
3. A patient with chronic obstructive pulmonary disease (COPD) presents with
increasing dyspnea. Which position is most effective to improve oxygenation?
A. Supine
B. Prone
C. High Fowler’s
D. Trendelenburg
Correct Answer: C. High Fowler’s
,Rationale: High Fowler’s position maximizes lung expansion and facilitates easier
breathing in patients with respiratory distress.
4. Which of the following is a sign of fluid overload in a post-operative client?
A. Dry mucous membranes
B. Peripheral edema
C. Hypotension
D. Tachycardia
Correct Answer: B. Peripheral edema
Rationale: Peripheral edema indicates excess fluid accumulation, a common sign
of fluid overload.
5. The nurse is caring for a client with a nasogastric tube. Which action should
the nurse take to prevent aspiration?
A. Keep the head of the bed elevated at 30–45 degrees
B. Place the client supine during feeding
C. Flush the tube only once daily
D. Administer large bolus feedings rapidly
Correct Answer: A. Keep the head of the bed elevated at 30–45 degrees
Rationale: Elevating the head reduces the risk of aspiration during tube feeding.
6. A patient is prescribed furosemide for heart failure. Which lab value should
the nurse monitor closely?
A. Sodium
B. Potassium
C. Creatinine
D. Glucose
Correct Answer: B. Potassium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia, which may
lead to cardiac arrhythmias.
7. Which of the following vaccines is recommended annually for all adults?
A. Influenza vaccine
B. Hepatitis B vaccine
C. MMR vaccine
, D. Varicella vaccine
Correct Answer: A. Influenza vaccine
Rationale: The influenza virus changes annually, requiring yearly vaccination for
optimal protection.
8. Which assessment finding indicates a client is experiencing right-sided heart
failure?
A. Pulmonary congestion
B. Peripheral edema
C. Dyspnea at rest
D. Crackles in the lungs
Correct Answer: B. Peripheral edema
Rationale: Right-sided heart failure leads to systemic venous congestion, causing
peripheral edema and jugular vein distension.
9. A patient receiving morphine reports severe constipation. Which intervention
is most appropriate?
A. Administer a stool softener
B. Increase opioid dosage
C. Restrict fluid intake
D. Encourage bed rest
Correct Answer: A. Administer a stool softener
Rationale: Opioids commonly cause constipation; stool softeners help prevent
complications and maintain bowel regularity.
10. Which of the following is the most reliable indicator of adequate fluid
replacement in a dehydrated patient?
A. Body weight
B. Skin turgor
C. Blood pressure
D. Urine output
Correct Answer: D. Urine output
Rationale: Urine output provides direct evidence of renal perfusion and effective
fluid replacement.