PLUS RATIONALES 2026 |INSTANT DOWNOAD PDF
1. A nurse is caring for a client who has heart failure and is
prescribed furosemide. Which of the following findings should
the nurse monitor?
A. Serum potassium level
B. Serum calcium level
C. Blood glucose level
D. Hemoglobin
Correct Answer: A. Serum potassium level — Furosemide is a
loop diuretic that can cause hypokalemia, so monitoring
potassium is essential.
2. A nurse is teaching a client about using an incentive
spirometer. Which instruction should the nurse include?
A. "Exhale forcefully into the device."
B. "Breathe in slowly to raise the indicator."
C. "Use the device after meals."
D. "Hold your breath for 1–2 seconds before exhaling."
Correct Answer: B. "Breathe in slowly to raise the indicator." —
Incentive spirometry promotes deep breathing to prevent
atelectasis.
,3. A nurse is assessing a client who has COPD. Which finding
should the nurse expect?
A. Bradycardia
B. Barrel-shaped chest
C. Hypothermia
D. Hypotension
Correct Answer: B. Barrel-shaped chest — Chronic air trapping
in COPD causes expansion of the chest wall.
4. A client is prescribed digoxin. Which statement indicates
the client understands the medication teaching?
A. "I will take my pulse before each dose."
B. "I can double the dose if I miss one."
C. "I should take it with grapefruit juice."
D. "I will stop the medication if I feel dizzy."
Correct Answer: A. "I will take my pulse before each dose." —
Digoxin can cause bradycardia, so monitoring the pulse is
crucial.
5. A nurse is caring for a client with a nasogastric (NG) tube.
Which action should the nurse take to prevent aspiration?
A. Keep the head of the bed flat
B. Verify tube placement before feedings
C. Flush with 10 mL of water every 12 hours
D. Clamp the tube after medication administration
,Correct Answer: B. Verify tube placement before feedings —
Ensures the tube is in the stomach, reducing the risk of
aspiration.
6. A nurse is teaching a client with type 1 diabetes about
hypoglycemia. Which symptom should the nurse include?
A. Polydipsia
B. Shakiness
C. Polyuria
D. Weight gain
Correct Answer: B. Shakiness — Hypoglycemia presents with
symptoms of adrenergic stimulation, like shakiness and
sweating.
7. A nurse is caring for a client with a new tracheostomy.
Which intervention should the nurse implement?
A. Suction for 30 seconds continuously
B. Use sterile technique for suctioning
C. Change the inner cannula monthly
D. Keep the cuff inflated at all times
Correct Answer: B. Use sterile technique for suctioning —
Prevents infection in the airway.
, 8. A nurse is teaching a client about taking warfarin. Which
statement indicates understanding?
A. "I will take aspirin if I have a headache."
B. "I need to have my INR checked regularly."
C. "I can double my dose if I miss one."
D. "I will avoid all green vegetables."
Correct Answer: B. "I need to have my INR checked regularly."
— Warfarin requires monitoring of clotting status to maintain
therapeutic effect.
9. A nurse is assessing a client who has a cast on the left arm.
Which finding requires immediate action?
A. Tingling in the fingers
B. Warm skin at cast edges
C. Able to move fingers
D. No edema present
Correct Answer: A. Tingling in the fingers — May indicate
neurovascular compromise requiring urgent intervention.
10. A client with hypothyroidism asks about medication
timing. Which instruction should the nurse give?
A. "Take the medication at bedtime with food."
B. "Take the medication in the morning on an empty stomach."
C. "Take the medication with calcium supplements."
D. "Take the medication only when feeling tired."