ADULT HEALTH NURSING DIAGNOSTIC ASSESSMENT TEST (QUESTIONS
AND CORRECT ANSWERS) FALL SERIES JULY/AUG 2026
1. A 68-year-old patient with a history of heart failure is admitted
with acute pulmonary edema. The nurse auscultates crackles
throughout the lung fields and notes an oxygen saturation of 88%
on 4L nasal cannula. Which intervention should the nurse initiate
first?
A. Administer a 500 mL normal saline bolus
B. Place the patient in a high-Fowler's position
C. Administer oral furosemide as prescribed
D. Prepare for immediate intubation
Correct Answer: B
Explanation: High-Fowler's position uses gravity to reduce venous
return and decrease pulmonary congestion, which improves
oxygenation. A saline bolus would worsen fluid overload. IV, not
oral, furosemide is needed for rapid effect. Intubation may become
necessary but is not the first action.
2. A patient with chronic kidney disease (CKD) has a serum
potassium level of 6.2 mEq/L. The nurse reviews the ECG and
notes peaked T-waves. Which intervention is a priority?
A. Administer oral sodium polystyrene sulfonate
B. Prepare for emergent hemodialysis
C. Administer intravenous calcium gluconate
D. Restrict dietary potassium intake
Correct Answer: C
, Explanation: IV calcium gluconate is the first-line treatment for
severe hyperkalemia to stabilize the cardiac membrane and
protect against dysrhythmias, as it acts within minutes. The other
options treat the potassium level but do not provide immediate
cardiac protection.
3. A patient is receiving a continuous heparin infusion for a deep vein
thrombosis. The aPTT result is 110 seconds. The nurse’s priority
action is to:
A. Increase the infusion rate
B. Continue the infusion and monitor
C. Stop the infusion and notify the provider
D. Administer protamine sulfate
Correct Answer: C
Explanation: This aPTT is significantly above the therapeutic range
(typically 1.5-2.5 times control), indicating a high risk of bleeding.
The infusion should be stopped and the provider notified.
Protamine sulfate is the antidote, but it is only given if there is
active, life-threatening bleeding.
4. The nurse is caring for a patient with diabetic ketoacidosis (DKA)
who is receiving an insulin drip. The patient's blood glucose has
decreased from 650 mg/dL to 250 mg/dL. Which intervention is
most important at this time?
A. Decrease the insulin infusion rate
B. Add dextrose to the IV fluids
C. Continue the insulin drip as ordered
, D. Administer a bolus of regular insulin
Correct Answer: B
Explanation: Once blood glucose reaches ~250 mg/dL in DKA,
dextrose is added to the IV fluids to prevent hypoglycemia while
continuing the insulin infusion to clear ketones. Decreasing or
stopping the insulin would allow ketone production to continue.
5. A patient newly diagnosed with type 1 diabetes asks the nurse
why they need to take insulin. The nurse's best response is based
on the understanding that:
A. The pancreas is producing excess glucagon
B. The body is resistant to the effects of insulin
C. The pancreas is unable to produce endogenous insulin
D. The liver is unable to store glucose as glycogen
Correct Answer: C
Explanation: Type 1 diabetes is an autoimmune destruction of the
pancreatic beta cells, leading to an absolute deficiency of insulin.
Type 2 diabetes is characterized by insulin resistance. Options A
and D are not primary causes.
6. The nurse is assessing a patient who has just returned from a
cardiac catheterization via the femoral artery. Which finding
requires immediate intervention?
A. A small hematoma at the insertion site
B. Patient reports mild pain at the site
C. The pedal pulse is palpable but weaker than baseline
D. The foot is pale, cool, and pulseless
, Correct Answer: D
Explanation: A pale, cool, and pulseless foot suggests arterial
occlusion and is a critical finding requiring immediate action. A
small hematoma and mild pain are expected. A weaker pedal
pulse may need monitoring but does not indicate complete
occlusion.
7. Which clinical manifestation is the nurse most likely to assess in a
patient with syndrome of inappropriate antidiuretic hormone
(SIADH)?
A. Peripheral edema and hypertension
B. Hyponatremia and decreased urine output
C. Hypernatremia and polyuria
D. Hyperkalemia and muscle weakness
Correct Answer: B
Explanation: In SIADH, there is excessive release of ADH, leading to
water retention, dilutional hyponatremia, and decreased urine
output. Edema is not typical as the fluid is retained intracellularly.
Hypernatremia and polyuria are seen in diabetes insipidus.
8. A patient with cirrhosis has an NG tube and is vomiting large
amounts of bright red blood. The nurse should prepare to
administer which medication?
A. Pantoprazole
B. Octreotide
C. Vitamin K
D. Lactulose
AND CORRECT ANSWERS) FALL SERIES JULY/AUG 2026
1. A 68-year-old patient with a history of heart failure is admitted
with acute pulmonary edema. The nurse auscultates crackles
throughout the lung fields and notes an oxygen saturation of 88%
on 4L nasal cannula. Which intervention should the nurse initiate
first?
A. Administer a 500 mL normal saline bolus
B. Place the patient in a high-Fowler's position
C. Administer oral furosemide as prescribed
D. Prepare for immediate intubation
Correct Answer: B
Explanation: High-Fowler's position uses gravity to reduce venous
return and decrease pulmonary congestion, which improves
oxygenation. A saline bolus would worsen fluid overload. IV, not
oral, furosemide is needed for rapid effect. Intubation may become
necessary but is not the first action.
2. A patient with chronic kidney disease (CKD) has a serum
potassium level of 6.2 mEq/L. The nurse reviews the ECG and
notes peaked T-waves. Which intervention is a priority?
A. Administer oral sodium polystyrene sulfonate
B. Prepare for emergent hemodialysis
C. Administer intravenous calcium gluconate
D. Restrict dietary potassium intake
Correct Answer: C
, Explanation: IV calcium gluconate is the first-line treatment for
severe hyperkalemia to stabilize the cardiac membrane and
protect against dysrhythmias, as it acts within minutes. The other
options treat the potassium level but do not provide immediate
cardiac protection.
3. A patient is receiving a continuous heparin infusion for a deep vein
thrombosis. The aPTT result is 110 seconds. The nurse’s priority
action is to:
A. Increase the infusion rate
B. Continue the infusion and monitor
C. Stop the infusion and notify the provider
D. Administer protamine sulfate
Correct Answer: C
Explanation: This aPTT is significantly above the therapeutic range
(typically 1.5-2.5 times control), indicating a high risk of bleeding.
The infusion should be stopped and the provider notified.
Protamine sulfate is the antidote, but it is only given if there is
active, life-threatening bleeding.
4. The nurse is caring for a patient with diabetic ketoacidosis (DKA)
who is receiving an insulin drip. The patient's blood glucose has
decreased from 650 mg/dL to 250 mg/dL. Which intervention is
most important at this time?
A. Decrease the insulin infusion rate
B. Add dextrose to the IV fluids
C. Continue the insulin drip as ordered
, D. Administer a bolus of regular insulin
Correct Answer: B
Explanation: Once blood glucose reaches ~250 mg/dL in DKA,
dextrose is added to the IV fluids to prevent hypoglycemia while
continuing the insulin infusion to clear ketones. Decreasing or
stopping the insulin would allow ketone production to continue.
5. A patient newly diagnosed with type 1 diabetes asks the nurse
why they need to take insulin. The nurse's best response is based
on the understanding that:
A. The pancreas is producing excess glucagon
B. The body is resistant to the effects of insulin
C. The pancreas is unable to produce endogenous insulin
D. The liver is unable to store glucose as glycogen
Correct Answer: C
Explanation: Type 1 diabetes is an autoimmune destruction of the
pancreatic beta cells, leading to an absolute deficiency of insulin.
Type 2 diabetes is characterized by insulin resistance. Options A
and D are not primary causes.
6. The nurse is assessing a patient who has just returned from a
cardiac catheterization via the femoral artery. Which finding
requires immediate intervention?
A. A small hematoma at the insertion site
B. Patient reports mild pain at the site
C. The pedal pulse is palpable but weaker than baseline
D. The foot is pale, cool, and pulseless
, Correct Answer: D
Explanation: A pale, cool, and pulseless foot suggests arterial
occlusion and is a critical finding requiring immediate action. A
small hematoma and mild pain are expected. A weaker pedal
pulse may need monitoring but does not indicate complete
occlusion.
7. Which clinical manifestation is the nurse most likely to assess in a
patient with syndrome of inappropriate antidiuretic hormone
(SIADH)?
A. Peripheral edema and hypertension
B. Hyponatremia and decreased urine output
C. Hypernatremia and polyuria
D. Hyperkalemia and muscle weakness
Correct Answer: B
Explanation: In SIADH, there is excessive release of ADH, leading to
water retention, dilutional hyponatremia, and decreased urine
output. Edema is not typical as the fluid is retained intracellularly.
Hypernatremia and polyuria are seen in diabetes insipidus.
8. A patient with cirrhosis has an NG tube and is vomiting large
amounts of bright red blood. The nurse should prepare to
administer which medication?
A. Pantoprazole
B. Octreotide
C. Vitamin K
D. Lactulose
