Questions with 100% Correct Answers and Rationale
(2026 Version)
1. A nurse is caring for a client who has heart failure and is short of breath. Which action
should the nurse take first?
A. Administer the prescribed diuretic
B. Check the client’s oxygen saturation
C. Position the client in high-Fowler’s
D. Auscultate lung sounds
Correct Answer: C
Rationale: Airway and breathing take priority. High-Fowler’s improves ventilation immediately.
2. A client with schizophrenia states, “The government implanted a device in my brain.”
Which response is therapeutic?
A. “That sounds frightening. Tell me more about how you’re feeling.”
B. “That’s not true; no one implanted anything.”
C. “Why do you believe that happened?”
D. “You should focus on positive thoughts instead.”
Correct Answer: A
Rationale: Acknowledges emotions and invites exploration without reinforcing delusions.
3. The nurse prepares to administer digoxin. Which finding requires holding the
medication?
A. BP 98/62
B. HR 54/min
C. Potassium 4.1
D. Respiratory rate 18/min
Correct Answer: B
Rationale: Digoxin should be held if HR < 60/min due to risk of bradycardia and toxicity.
4. A nurse cares for a client receiving a blood transfusion. Which assessment indicates a
hemolytic reaction?
A. Urticaria and itching
B. Back pain and hypotension
C. Fever and chills
D. Dyspnea and anxiety
Correct Answer: B
Rationale: Hemolytic reactions present with low back pain, hypotension, tachycardia, and
hemoglobinuria.
5. A toddler with dehydration is prescribed oral rehydration solution. Which finding
indicates improvement?
A. Decreased urine output
,B. Capillary refill > 3 seconds
C. Moist mucous membranes
D. Sunken fontanel
Correct Answer: C
Rationale: Moist mucous membranes indicate adequate hydration.
6. A nurse teaches a client taking warfarin. Which statement indicates understanding?
A. “I can take aspirin if I have pain.”
B. “I will increase green leafy vegetables to prevent bleeding.”
C. “I will keep my INR checks scheduled.”
D. “I should double my dose if I miss one.”
Correct Answer: C
Rationale: INR monitoring is essential for safe anticoagulation.
7. (SATA) A nurse reviews labs for a client receiving total parenteral nutrition (TPN).
Which findings should be reported?
• A. Sodium 143
• B. Glucose 312
• C. Potassium 2.9
• D. Albumin 3.8
• E. Magnesium 1.1
Correct Answers: B, C, E
Rationale: Hyperglycemia, hypokalemia, and hypomagnesemia are complications requiring
intervention.
8. A nurse is caring for a client with COPD. Which oxygen delivery device is most
appropriate for long-term home therapy?
A. Nonrebreather mask
B. Simple face mask
C. Venturi mask
D. Nasal cannula
Correct Answer: D
Rationale: Nasal cannula supports low-flow, long-term oxygen therapy suitable for COPD.
9. A nurse assesses an older adult with suspected pneumonia. Which finding is expected?
A. Productive cough
B. Night sweats
C. Confusion
D. Hyperactivity
Correct Answer: C
Rationale: Older adults often present with atypical symptoms such as confusion or altered
mental status.
10. The nurse prepares to discharge a client beginning sertraline. Which teaching is most
important?
A. “Take this medication with food.”
, B. “Improvement may take 2–4 weeks.”
C. “You may stop the medication once you feel better.”
D. “Avoid cheese and smoked meats.”
Correct Answer: B
Rationale: SSRIs require several weeks for therapeutic effect.
11. A nurse is caring for a client with a chest tube on suction. Which finding requires
immediate intervention?
A. Gentle bubbling in the suction chamber
B. Tidaling in the water seal
C. Continuous bubbling in the water seal
D. 20 mL/hr of serosanguinous drainage
Correct Answer: C
Rationale: Continuous bubbling in the water seal indicates an air leak, requiring rapid
assessment.
12. A client receiving morphine IV reports difficulty breathing. Respirations are 8/min.
What should the nurse do first?
A. Notify the provider
B. Administer naloxone
C. Increase IV fluids
D. Reassess in 15 minutes
Correct Answer: B
Rationale: Low respirations indicate opioid toxicity; naloxone is the priority.
13. A nurse provides discharge teaching to a client with chronic pancreatitis. Which
instruction is correct?
A. “Limit carbohydrate intake.”
B. “Avoid high-protein snacks.”
C. “Take pancreatic enzymes with meals.”
D. “Expect stools to be hard and dry.”
Correct Answer: C
Rationale: Enzymes aid digestion and must be taken with meals.
14. (SATA) A nurse is assessing a client with hyperthyroidism. Expected findings include:
• A. Heat intolerance
• B. Weight gain
• C. Tremors
• D. Tachycardia
• E. Dry, thick skin
Correct Answers: A, C, D
Rationale: Hyperthyroidism increases metabolism → tremors, tachycardia, heat intolerance.
15. A nurse evaluates a client’s pain response after medication. Which step of the nursing
process is this?
A. Assessment