NR 326 CMS Exam (Answered)
With Rationale Graded A+
Course
NR 326
1. A nurse is caring for a client with heart failure who reports increasing shortness of
breath and weight gain of 5 lb (2.3 kg) in one week. What is the nurse's priority action?
A. Encourage increased fluid intake
B. Assess lung sounds and oxygen saturation
C. Administer pain medication
D. Restrict activity for 24 hours
Answer: B. Assess lung sounds and oxygen saturation
Rationale:
Rapid weight gain and dyspnea suggest fluid overload and worsening heart failure. Assessing
respiratory status helps determine the severity of the condition and guides immediate
interventions.
2. A client with Type 2 diabetes has a blood glucose level of 52 mg/dL. The client is alert and
able to swallow. What should the nurse do first?
A. Administer glucagon IM
B. Provide 15 g of fast-acting carbohydrates
C. Start IV dextrose
D. Notify the provider
Answer: B. Provide 15 g of fast-acting carbohydrates
Rationale:
For conscious clients with hypoglycemia, the first intervention is administering 15 g of a rapid-
acting carbohydrate, followed by reassessment of blood glucose.
3. Which assessment finding requires immediate intervention in a postoperative client?
A. Pain rated 4/10
B. Respiratory rate of 8/min
C. Temperature of 37.5°C (99.5°F)
D. Blood pressure of 128/76 mm Hg
Answer: B. Respiratory rate of 8/min
,Rationale:
A respiratory rate below 12/min may indicate respiratory depression and requires immediate
evaluation and intervention.
4. A nurse is teaching a client prescribed warfarin. Which statement by the client indicates
understanding?
A. "I will increase my intake of green leafy vegetables."
B. "I will use a soft-bristle toothbrush."
C. "I can take aspirin for headaches."
D. "I do not need blood tests."
Answer: B. "I will use a soft-bristle toothbrush."
Rationale:
Warfarin increases bleeding risk. Using a soft toothbrush helps prevent gum bleeding. Consistent
vitamin K intake and regular INR monitoring are essential.
5. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy.
Which finding indicates effective treatment?
A. Increased restlessness
B. Oxygen saturation of 92%
C. Respiratory rate of 34/min
D. Use of accessory muscles
Answer: B. Oxygen saturation of 92%
Rationale:
For many COPD clients, maintaining oxygen saturation between 88% and 92% indicates
adequate oxygenation.
6. Which laboratory value should the nurse report immediately?
A. Hemoglobin 13.5 g/dL
B. Potassium 2.8 mEq/L
C. Sodium 138 mEq/L
D. White blood cell count 8,000/mm³
Answer: B. Potassium 2.8 mEq/L
,Rationale:
Severe hypokalemia can cause life-threatening cardiac dysrhythmias and requires prompt
intervention.
7. A client with a stroke has difficulty swallowing. Which action should the nurse take?
A. Offer thin liquids frequently
B. Place the client in a supine position for meals
C. Consult speech therapy before oral feeding
D. Encourage rapid eating
Answer: C. Consult speech therapy before oral feeding
Rationale:
A swallowing evaluation is needed to reduce the risk of aspiration in clients with dysphagia.
8. Which finding suggests a client is experiencing an allergic reaction to a medication?
A. Blood pressure 122/78 mm Hg
B. Urticaria and wheezing
C. Heart rate 82/min
D. Temperature 37°C (98.6°F)
Answer: B. Urticaria and wheezing
Rationale:
Hives and wheezing are common manifestations of an allergic reaction and may indicate
anaphylaxis.
9. A nurse is caring for a client with dehydration. Which assessment finding indicates
improvement?
A. Urine output 10 mL/hr
B. Dry mucous membranes
C. Capillary refill less than 2 seconds
D. Tachycardia
Answer: C. Capillary refill less than 2 seconds
Rationale:
Normal capillary refill reflects improved circulation and hydration status.
, 10. A nurse is preparing to discharge a client with hypertension. Which statement indicates
a need for further teaching?
A. "I will take my medication even when I feel well."
B. "I will monitor my blood pressure regularly."
C. "I can stop my medication when my blood pressure becomes normal."
D. "I will reduce sodium in my diet."
Answer: C. "I can stop my medication when my blood pressure becomes normal."
Rationale:
Hypertension often requires lifelong management. Stopping medication without provider
approval can lead to uncontrolled blood pressure and complications.
11. A client receiving IV furosemide reports dizziness when standing. What is the nurse's
priority assessment?
A. Bowel sounds
B. Orthostatic blood pressure
C. Visual acuity
D. Reflexes
Answer: B. Orthostatic blood pressure
Rationale:
Furosemide can cause volume depletion and orthostatic hypotension, increasing fall risk.
12. Which client should the nurse assess first?
A. Client with pain rated 6/10
B. Client requesting discharge instructions
C. Client with chest pain and diaphoresis
D. Client awaiting laboratory results
Answer: C. Client with chest pain and diaphoresis
Rationale:
Chest pain with diaphoresis may indicate myocardial infarction and requires immediate
assessment.
13. A client with pneumonia has an oxygen saturation of 86% on room air. What is the
nurse's first action?
With Rationale Graded A+
Course
NR 326
1. A nurse is caring for a client with heart failure who reports increasing shortness of
breath and weight gain of 5 lb (2.3 kg) in one week. What is the nurse's priority action?
A. Encourage increased fluid intake
B. Assess lung sounds and oxygen saturation
C. Administer pain medication
D. Restrict activity for 24 hours
Answer: B. Assess lung sounds and oxygen saturation
Rationale:
Rapid weight gain and dyspnea suggest fluid overload and worsening heart failure. Assessing
respiratory status helps determine the severity of the condition and guides immediate
interventions.
2. A client with Type 2 diabetes has a blood glucose level of 52 mg/dL. The client is alert and
able to swallow. What should the nurse do first?
A. Administer glucagon IM
B. Provide 15 g of fast-acting carbohydrates
C. Start IV dextrose
D. Notify the provider
Answer: B. Provide 15 g of fast-acting carbohydrates
Rationale:
For conscious clients with hypoglycemia, the first intervention is administering 15 g of a rapid-
acting carbohydrate, followed by reassessment of blood glucose.
3. Which assessment finding requires immediate intervention in a postoperative client?
A. Pain rated 4/10
B. Respiratory rate of 8/min
C. Temperature of 37.5°C (99.5°F)
D. Blood pressure of 128/76 mm Hg
Answer: B. Respiratory rate of 8/min
,Rationale:
A respiratory rate below 12/min may indicate respiratory depression and requires immediate
evaluation and intervention.
4. A nurse is teaching a client prescribed warfarin. Which statement by the client indicates
understanding?
A. "I will increase my intake of green leafy vegetables."
B. "I will use a soft-bristle toothbrush."
C. "I can take aspirin for headaches."
D. "I do not need blood tests."
Answer: B. "I will use a soft-bristle toothbrush."
Rationale:
Warfarin increases bleeding risk. Using a soft toothbrush helps prevent gum bleeding. Consistent
vitamin K intake and regular INR monitoring are essential.
5. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy.
Which finding indicates effective treatment?
A. Increased restlessness
B. Oxygen saturation of 92%
C. Respiratory rate of 34/min
D. Use of accessory muscles
Answer: B. Oxygen saturation of 92%
Rationale:
For many COPD clients, maintaining oxygen saturation between 88% and 92% indicates
adequate oxygenation.
6. Which laboratory value should the nurse report immediately?
A. Hemoglobin 13.5 g/dL
B. Potassium 2.8 mEq/L
C. Sodium 138 mEq/L
D. White blood cell count 8,000/mm³
Answer: B. Potassium 2.8 mEq/L
,Rationale:
Severe hypokalemia can cause life-threatening cardiac dysrhythmias and requires prompt
intervention.
7. A client with a stroke has difficulty swallowing. Which action should the nurse take?
A. Offer thin liquids frequently
B. Place the client in a supine position for meals
C. Consult speech therapy before oral feeding
D. Encourage rapid eating
Answer: C. Consult speech therapy before oral feeding
Rationale:
A swallowing evaluation is needed to reduce the risk of aspiration in clients with dysphagia.
8. Which finding suggests a client is experiencing an allergic reaction to a medication?
A. Blood pressure 122/78 mm Hg
B. Urticaria and wheezing
C. Heart rate 82/min
D. Temperature 37°C (98.6°F)
Answer: B. Urticaria and wheezing
Rationale:
Hives and wheezing are common manifestations of an allergic reaction and may indicate
anaphylaxis.
9. A nurse is caring for a client with dehydration. Which assessment finding indicates
improvement?
A. Urine output 10 mL/hr
B. Dry mucous membranes
C. Capillary refill less than 2 seconds
D. Tachycardia
Answer: C. Capillary refill less than 2 seconds
Rationale:
Normal capillary refill reflects improved circulation and hydration status.
, 10. A nurse is preparing to discharge a client with hypertension. Which statement indicates
a need for further teaching?
A. "I will take my medication even when I feel well."
B. "I will monitor my blood pressure regularly."
C. "I can stop my medication when my blood pressure becomes normal."
D. "I will reduce sodium in my diet."
Answer: C. "I can stop my medication when my blood pressure becomes normal."
Rationale:
Hypertension often requires lifelong management. Stopping medication without provider
approval can lead to uncontrolled blood pressure and complications.
11. A client receiving IV furosemide reports dizziness when standing. What is the nurse's
priority assessment?
A. Bowel sounds
B. Orthostatic blood pressure
C. Visual acuity
D. Reflexes
Answer: B. Orthostatic blood pressure
Rationale:
Furosemide can cause volume depletion and orthostatic hypotension, increasing fall risk.
12. Which client should the nurse assess first?
A. Client with pain rated 6/10
B. Client requesting discharge instructions
C. Client with chest pain and diaphoresis
D. Client awaiting laboratory results
Answer: C. Client with chest pain and diaphoresis
Rationale:
Chest pain with diaphoresis may indicate myocardial infarction and requires immediate
assessment.
13. A client with pneumonia has an oxygen saturation of 86% on room air. What is the
nurse's first action?
