Level 2 (2025_2026)
Original Questions | Answers | Rationales
1. A nurse is caring for a client receiving total parenteral
nutrition (TPN). Which finding requires immediate
intervention?
A. Blood glucose 128 mg/dL
B. Weight gain of 1 kg in 24 hr
C. Mild thirst
D. Clear yellow urine
Correct Answer: B
Rationale: A 1-kg/day weight gain indicates fluid overload, a serious complication of TPN.
2. A nurse teaches a client taking furosemide. Which
statement indicates understanding?
A. “I will avoid potassium-rich foods.”
B. “I should weigh myself daily.”
C. “This medication will raise my blood pressure.”
D. “I can stop it if my swelling improves.”
,Correct Answer: B
Rationale: Daily weights detect fluid changes from diuresis.
3. A client with COPD reports shortness of breath.
Priority action?
A. Increase IV fluids
B. Encourage pursed-lip breathing
C. Apply 4 L/min oxygen
D. Administer cough suppressant
Correct Answer: B
Rationale: Pursed-lip breathing improves CO₂ elimination and reduces dyspnea.
4. A nurse prepares to administer digoxin. Which finding
requires withholding the dose?
A. HR 54/min
B. BP 110/65
C. K⁺ 4.0 mEq/L
D. O₂ sat 95%
Correct Answer: A
Rationale: Hold digoxin for HR < 60/min.
5. A nurse teaches about insulin storage. Which
instruction is correct?
A. “Freeze unopened insulin.”
B. “Keep in direct sunlight.”
C. “Refrigerate unopened insulin vials.”
D. “Throw away after 2 years.”
Correct Answer: C
Rationale: Unopened insulin should be refrigerated.
, 6. Priority nursing action for a client with a potassium
level of 2.7 mEq/L?
A. Place on seizure precautions
B. Initiate continuous cardiac monitoring
C. Restrict oral fluids
D. Administer calcium gluconate
Correct Answer: B
Rationale: Severe hypokalemia causes fatal arrhythmias.
7. A client with pneumonia has thick secretions. Which
intervention is best?
A. Decrease fluid intake
B. Humidified oxygen
C. Place in high Fowler’s
D. Provide antitussive medication
Correct Answer: B
Rationale: Humidification thins secretions for easier clearance.
8. A nurse prepares to administer IV vancomycin. Priority
assessment?
A. Lung sounds
B. Liver function
C. Kidney function
D. Bowel elimination
Correct Answer: C
Rationale: Vancomycin is nephrotoxic.