1|Page
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Q1
A 65-year-old patient with chronic heart failure presents with shortness of breath and
peripheral edema. Which assessment finding indicates fluid overload?
A. Dry mucous membranes
B. Distended neck veins
C. Bradycardia
D. Hypotension
Correct Answer: B
Verified Explanation
Distended neck veins, or jugular venous distention (JVD), are a hallmark sign of fluid
overload in patients with heart failure. This occurs because excess circulating fluid increases
venous pressure, which is transmitted backward to the jugular veins. Peripheral edema often
accompanies JVD, reflecting fluid accumulation in dependent tissues. Dry mucous
membranes indicate dehydration, bradycardia may be unrelated, and hypotension may occur
in late decompensation but is not a primary fluid overload sign. Accurate assessment of fluid
status is essential in heart failure management to guide interventions like diuretics, fluid
restriction, and monitoring of weight changes.
Q2
A patient with type 2 diabetes has a fasting blood glucose of 180 mg/dL. Which intervention
is most appropriate?
A. Encourage insulin only
B. Administer oral hypoglycemic agents
C. Increase carbohydrate intake
D. Hold all medications
Correct Answer: B
Verified Explanation
For type 2 diabetes with elevated fasting glucose, oral hypoglycemic agents (like metformin
or sulfonylureas) are appropriate first-line therapy. These medications improve insulin
sensitivity or stimulate insulin secretion. Insulin therapy may be needed if oral agents are
insufficient, but it is not the initial step for many patients. Increasing carbohydrate intake
would worsen hyperglycemia, and holding medications would allow uncontrolled blood
glucose, increasing the risk of complications such as neuropathy, nephropathy, and
cardiovascular events. Nursing interventions also include lifestyle modifications, diet
management, and patient education to maintain long-term glycemic control.
,3|Page
Q3
Which electrolyte imbalance is most likely in a patient taking loop diuretics for hypertension?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Correct Answer: B
Verified Explanation
Loop diuretics, such as furosemide, increase renal excretion of sodium, water, potassium,
calcium, and magnesium. The most clinically significant electrolyte imbalance is
hypokalemia, as potassium loss can lead to arrhythmias, muscle weakness, and fatigue.
Hyperkalemia is unlikely because loop diuretics promote potassium excretion. Hypernatremia
rarely occurs because sodium is excreted along with water, and hypocalcemia—not
hypercalcemia—can result from calcium loss. Nursing care involves monitoring serum
electrolytes, ECG changes, and advising potassium-rich foods or supplements. Early
recognition and intervention prevent serious complications, making electrolyte monitoring a
core aspect of patient safety.
Q4
A patient develops tachycardia, hypotension, and a rash after receiving a blood transfusion.
What is the priority nursing action?
A. Document and continue transfusion
B. Stop the transfusion immediately
C. Slow the transfusion rate
D. Administer a diuretic
Correct Answer: B
Verified Explanation
The patient is showing signs of a transfusion reaction, potentially anaphylactic or hemolytic.
Tachycardia, hypotension, and rash are early indicators. The priority is to stop the transfusion
immediately to prevent further antigen-antibody reaction or worsening anaphylaxis. The
nurse should maintain IV access with normal saline, monitor vital signs, notify the provider,
and prepare for emergency interventions such as epinephrine if indicated. Documentation and
transfusion rate adjustments come after ensuring patient safety. Prompt recognition and
stopping the transfusion is a life-saving intervention and is emphasized in nursing standards
for blood administration safety.
Q5
, 4|Page
Which patient statement best indicates understanding of warfarin therapy?
A. “I will take extra doses if I miss one.”
B. “I should monitor for unusual bleeding and bruising.”
C. “I can take aspirin anytime for headaches.”
D. “I do not need follow-up blood tests.”
Correct Answer: B
Verified Explanation
Patients on warfarin, an anticoagulant, must monitor for signs of bleeding, including bruising,
nosebleeds, hematuria, or gastrointestinal bleeding. Taking extra doses can cause dangerous
hemorrhage, and concurrent use of aspirin increases bleeding risk due to additive antiplatelet
effects. Regular blood tests, such as INR (International Normalized Ratio), are critical to
ensure therapeutic anticoagulation. Patient education focuses on medication adherence,
dietary considerations (vitamin K intake), and reporting any abnormal bleeding immediately.
Understanding these safety precautions reflects comprehension of warfarin therapy and helps
prevent life-threatening complications while ensuring effective anticoagulation.
Q6
A patient with COPD reports increased dyspnea and a productive cough with purulent
sputum. What is the most likely nursing diagnosis?
A. Risk for falls
B. Impaired gas exchange
C. Fluid volume deficit
D. Ineffective coping
Correct Answer: B
Verified Explanation
In a patient with COPD (chronic obstructive pulmonary disease), impaired gas exchange is
the most appropriate nursing diagnosis when dyspnea and purulent sputum indicate airway
obstruction and inflammation. The accumulation of mucus and inflammation reduces alveolar
oxygen diffusion, resulting in hypoxemia. Risk for falls may be secondary but is not
immediate, fluid volume deficit is unrelated, and ineffective coping addresses psychological
aspects. Nursing interventions include oxygen therapy, airway clearance techniques,
medication administration (bronchodilators, antibiotics), monitoring oxygen saturation, and
patient education to prevent exacerbations. Correct diagnosis guides targeted interventions to
maintain oxygenation and reduce respiratory distress.
Q7
Which intervention is priority for a patient experiencing hypoglycemia (blood glucose 50
mg/dL)?
,2|Page
Q1
A 65-year-old patient with chronic heart failure presents with shortness of breath and
peripheral edema. Which assessment finding indicates fluid overload?
A. Dry mucous membranes
B. Distended neck veins
C. Bradycardia
D. Hypotension
Correct Answer: B
Verified Explanation
Distended neck veins, or jugular venous distention (JVD), are a hallmark sign of fluid
overload in patients with heart failure. This occurs because excess circulating fluid increases
venous pressure, which is transmitted backward to the jugular veins. Peripheral edema often
accompanies JVD, reflecting fluid accumulation in dependent tissues. Dry mucous
membranes indicate dehydration, bradycardia may be unrelated, and hypotension may occur
in late decompensation but is not a primary fluid overload sign. Accurate assessment of fluid
status is essential in heart failure management to guide interventions like diuretics, fluid
restriction, and monitoring of weight changes.
Q2
A patient with type 2 diabetes has a fasting blood glucose of 180 mg/dL. Which intervention
is most appropriate?
A. Encourage insulin only
B. Administer oral hypoglycemic agents
C. Increase carbohydrate intake
D. Hold all medications
Correct Answer: B
Verified Explanation
For type 2 diabetes with elevated fasting glucose, oral hypoglycemic agents (like metformin
or sulfonylureas) are appropriate first-line therapy. These medications improve insulin
sensitivity or stimulate insulin secretion. Insulin therapy may be needed if oral agents are
insufficient, but it is not the initial step for many patients. Increasing carbohydrate intake
would worsen hyperglycemia, and holding medications would allow uncontrolled blood
glucose, increasing the risk of complications such as neuropathy, nephropathy, and
cardiovascular events. Nursing interventions also include lifestyle modifications, diet
management, and patient education to maintain long-term glycemic control.
,3|Page
Q3
Which electrolyte imbalance is most likely in a patient taking loop diuretics for hypertension?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Correct Answer: B
Verified Explanation
Loop diuretics, such as furosemide, increase renal excretion of sodium, water, potassium,
calcium, and magnesium. The most clinically significant electrolyte imbalance is
hypokalemia, as potassium loss can lead to arrhythmias, muscle weakness, and fatigue.
Hyperkalemia is unlikely because loop diuretics promote potassium excretion. Hypernatremia
rarely occurs because sodium is excreted along with water, and hypocalcemia—not
hypercalcemia—can result from calcium loss. Nursing care involves monitoring serum
electrolytes, ECG changes, and advising potassium-rich foods or supplements. Early
recognition and intervention prevent serious complications, making electrolyte monitoring a
core aspect of patient safety.
Q4
A patient develops tachycardia, hypotension, and a rash after receiving a blood transfusion.
What is the priority nursing action?
A. Document and continue transfusion
B. Stop the transfusion immediately
C. Slow the transfusion rate
D. Administer a diuretic
Correct Answer: B
Verified Explanation
The patient is showing signs of a transfusion reaction, potentially anaphylactic or hemolytic.
Tachycardia, hypotension, and rash are early indicators. The priority is to stop the transfusion
immediately to prevent further antigen-antibody reaction or worsening anaphylaxis. The
nurse should maintain IV access with normal saline, monitor vital signs, notify the provider,
and prepare for emergency interventions such as epinephrine if indicated. Documentation and
transfusion rate adjustments come after ensuring patient safety. Prompt recognition and
stopping the transfusion is a life-saving intervention and is emphasized in nursing standards
for blood administration safety.
Q5
, 4|Page
Which patient statement best indicates understanding of warfarin therapy?
A. “I will take extra doses if I miss one.”
B. “I should monitor for unusual bleeding and bruising.”
C. “I can take aspirin anytime for headaches.”
D. “I do not need follow-up blood tests.”
Correct Answer: B
Verified Explanation
Patients on warfarin, an anticoagulant, must monitor for signs of bleeding, including bruising,
nosebleeds, hematuria, or gastrointestinal bleeding. Taking extra doses can cause dangerous
hemorrhage, and concurrent use of aspirin increases bleeding risk due to additive antiplatelet
effects. Regular blood tests, such as INR (International Normalized Ratio), are critical to
ensure therapeutic anticoagulation. Patient education focuses on medication adherence,
dietary considerations (vitamin K intake), and reporting any abnormal bleeding immediately.
Understanding these safety precautions reflects comprehension of warfarin therapy and helps
prevent life-threatening complications while ensuring effective anticoagulation.
Q6
A patient with COPD reports increased dyspnea and a productive cough with purulent
sputum. What is the most likely nursing diagnosis?
A. Risk for falls
B. Impaired gas exchange
C. Fluid volume deficit
D. Ineffective coping
Correct Answer: B
Verified Explanation
In a patient with COPD (chronic obstructive pulmonary disease), impaired gas exchange is
the most appropriate nursing diagnosis when dyspnea and purulent sputum indicate airway
obstruction and inflammation. The accumulation of mucus and inflammation reduces alveolar
oxygen diffusion, resulting in hypoxemia. Risk for falls may be secondary but is not
immediate, fluid volume deficit is unrelated, and ineffective coping addresses psychological
aspects. Nursing interventions include oxygen therapy, airway clearance techniques,
medication administration (bronchodilators, antibiotics), monitoring oxygen saturation, and
patient education to prevent exacerbations. Correct diagnosis guides targeted interventions to
maintain oxygenation and reduce respiratory distress.
Q7
Which intervention is priority for a patient experiencing hypoglycemia (blood glucose 50
mg/dL)?
