Questions & Detailed Answers | 2023 Test Questions with
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QUESTION 1
A nurse is assessing a client who is 12 hours postoperative following a colon resection. Which of the
following findings should the nurse report to the surgeon?
A. Temperature of 37.2°C (99.0°F)
B. Heart rate of 88/min
C. Blood pressure 88/52 mm Hg
D. Respiratory rate of 18/min
Answer: C. Blood pressure 88/52 mm Hg
Explanation: Hypotension (systolic BP <90 mm Hg) in a postoperative patient may indicate internal
bleeding, hypovolemia, or sepsis. This finding requires immediate notification of the surgeon. The other
vital signs are within normal limits.
QUESTION 2
A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide.
Which of the following statements indicates an understanding of the teaching?
A. "I should take this medication with food."
B. "I will weigh myself daily and report a weight gain of 2 pounds in one day."
C. "I should restrict my fluid intake to 3 liters per day."
D. "I can stop taking this medication when I feel better."
,Answer: B. "I will weigh myself daily and report a weight gain of 2 pounds in one day."
Explanation: Daily weights are essential for monitoring fluid status in heart failure. A weight gain of 23
pounds in a day or 5 pounds in a week indicates fluid retention and should be reported. Furosemide is a
loop diuretic that should be taken in the morning to avoid nocturia.
QUESTION 3
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has oxygen
saturation of 88% on room air. Which of the following actions should the nurse take?
A. Administer oxygen at 4 L/min via nasal cannula
B. Administer oxygen at 2 L/min via nasal cannula
C. Place the client in Trendelenburg position
D. Encourage the client to cough and deep breathe
Answer: B. Administer oxygen at 2 L/min via nasal cannula
Explanation: Clients with COPD should receive lowflow oxygen (12 L/min) to avoid suppressing the
hypoxic drive. Highflow oxygen can lead to respiratory depression and CO₂ retention. Target SpO₂ for
COPD patients is typically 8892%.
QUESTION 4
A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the following findings should
the nurse expect?
A. Blood glucose 120 mg/dL
B. Kussmaul respirations
,C. Hypothermia
D. Hypertension
Answer: B. Kussmaul respirations
Explanation: Kussmaul respirations (deep, rapid breathing) are a compensatory mechanism in DKA to
blow off excess CO₂ and correct metabolic acidosis. Other expected findings include blood glucose >250
mg/dL, ketonuria, polyuria, polydipsia, and fruity breath odor.
QUESTION 5
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following
manifestations should the nurse expect?
A. Polyuria, polydipsia, polyphagia
B. Weight gain
C. Hypotension
D. Bradycardia
Answer: A. Polyuria, polydipsia, polyphagia
Explanation: The classic "three Ps" of type 1 diabetes are polyuria (excessive urination), polydipsia
(excessive thirst), and polyphagia (excessive hunger). These result from hyperglycemia causing osmotic
diuresis and cellular dehydration.
QUESTION 6
A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should
the nurse take first?
, A. Obtain vital signs
B. Verify the client's identity using two identifiers
C. Prime the blood tubing with normal saline
D. Check the expiration date on the blood product
Answer: B. Verify the client's identity using two identifiers
Explanation: Patient identification is the priority before any blood transfusion. The nurse must verify the
client using two identifiers (name and date of birth) and match this to the blood product label and the
blood bank identification number. This is a critical safety step to prevent transfusion errors.
QUESTION 7
A nurse is caring for a client who has acute kidney injury (AKI). Which of the following laboratory
findings should the nurse expect?
A. Elevated serum creatinine
B. Decreased blood urea nitrogen (BUN)
C. Elevated serum calcium
D. Decreased potassium
Answer: A. Elevated serum creatinine
Explanation: In AKI, the kidneys cannot effectively filter waste products, leading to elevated serum
creatinine and BUN. Hyperkalemia, hyperphosphatemia, and metabolic acidosis are also expected.
Hypocalcemia may occur.