EXAM 2026 2027 DETAILED CORRECT
ANSWERS WITH RATIONALES GRADE A+
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1. A nurse in the emergency department is caring for a client who
presents with a severe laceration to the left forearm, diaphoresis,
and a blood pressure of 86/42 mm Hg. Which of the following
prescribed interventions should the nurse perform first?
A. Administer a 2 g dose of intravenous cephalosporin to prevent
secondary wound infection.
B. Initiate rapid regular administration of a 0.9% sodium
chloride 1,000 mL intravenous bolus.
C. Apply a sterile, non-adherent dressing to the wound site and
wrap it with an elastic bandage.
D. Obtain a clean-catch urine specimen for a comprehensive
urinalysis and toxicological screen.
Correct Answer: B
Rationale: The client exhibits clear signs of hypovolaemic shock
due to blood loss, characterized by severe hypotension and
diaphoresis. According to the airway, breathing, circulation
(ABC) priority framework, restoring circulating blood volume to
maintain organ perfusion is the most critical immediate
intervention, making isotonic fluid resuscitation the absolute first
action.
2. A nurse is reviewing the electronic health record of a client who
has a prescription for a continuous intravenous infusion of heparin
for deep-vein thrombosis. Which of the following laboratory values
requires immediate notification of the provider?
A. Activated partial thromboplastin time (aPTT) of 65 seconds.
B. Hemoglobin level of 13.8 g/dL.
C. Platelet count of 84,000/mm³.
D. Prothrombin time (PT) of 12 seconds.
, Correct Answer: C
Rationale: A platelet count below 100,000/mm³, or a drop of
greater than 50% from baseline, indicates Heparin-Induced
Thrombocytopenia (HIT). HIT is a life-threatening, immune-
mediated complication that puts the client at high risk for
paradoxical thromboembolic events and requires immediate
cessation of heparin therapy.
3. A nurse on a medical-surgical unit is preparing to administer
digoxin 0.25 mg PO to an older adult client who has heart failure.
Which of the following laboratory results should the nurse evaluate
before administering the dose?
A. Serum sodium level of 138 mEq/L.
B. Serum potassium level of 3.2 mEq/L.
C. Blood urea nitrogen (BUN) of 18 mg/dL.
D. Serum calcium level of 9.5 mg/dL.
Correct Answer: B
Rationale: Hypokalemia (serum potassium less than 3.5 mEq/L)
significantly increases the risk of digoxin toxicity because low
potassium allows digoxin to bind more easily to myocardial cell
receptors. The nurse must check both the apical pulse and the
potassium level before administration to prevent fatal cardiac
arrhythmias.
4. A nurse is monitoring a client who is 12 hours postoperative
following a total thyroidectomy. The client reports a tingling
sensation around their mouth and muscle twitching in their right
hand when their blood pressure is measured. Which of the
following medications should the nurse prepare to administer?
A. Potassium chloride intravenously.
B. Calcium gluconate intravenously.
C. Sodium bicarbonate orally.
D. Magnesium sulfate intramuscularly.
Correct Answer: B
Rationale: Tingling around the mouth (circumoral paresthesia)
and muscle spasms during blood pressure cuff inflation
(Trousseau's sign) are classic signs of acute hypocalcaemia. This
occurs post-thyroidectomy due to accidental damage or removal
of the parathyroid glands, requiring immediate IV calcium
gluconate replacement to prevent laryngospasm.
,5. A nurse in a mental health facility is assessing a client who has
schizophrenia and was recently started on haloperidol. The nurse
notes that the client has a temperature of 39.4°C (103°F), severe
muscle rigidity, and a fluctuating blood pressure. Which of the
following complications should the nurse suspect?
A. Acute dystonic reaction.
B. Neuroleptic malignant syndrome (NMS).
C. Tardive dyskinesia.
D. Serotonin syndrome.
Correct Answer: B
Rationale: Neuroleptic malignant syndrome (NMS) is a rare, life-
threatening reaction to antipsychotic medications like
haloperidol. The hallmark symptoms include high fever
(hyperpyrexia), muscular rigidity ("lead-pipe" rigidity), altered
mental status, and autonomic instability (fluctuating blood
pressure and tachycardia).
6. A nurse is planning care for a client who has a prescription for a
continuous lumbar epidural infusion for labor pain management.
Which of the following actions should the nurse include in the plan
of care?
A. Maintain the client in a lithotomy position throughout the active
labor phase.
B. Administer a 500 mL to 1,000 mL bolus of an isotonic
IV fluid prior to initiation.
C. Restrict the client's oral intake to clear liquids for 24 hours
following delivery.
D. Instruct the client to remain completely flat on their back for 8
hours post-procedure.
Correct Answer: B
Rationale: Epidural anesthesia induces vasodilation, which
frequently causes maternal hypotension. Administering a fluid
bolus of 0.9% sodium chloride or Lactated Ringer's before the
epidural is started helps expand intravascular volume and
prevents sudden, severe drops in blood pressure that could
compromise fetal perfusion.
7. A nurse is assessing an infant who is 4 hours postoperative
following a cleft lip repair. Which of the following actions should
the nurse take to prevent trauma to the surgical site?
A. Place the infant in a prone position for sleep cycles.
, B. Apply soft elbow restraints to the infant's upper
extremities.
C. Use a standard firm nipple for all formula feedings.
D. Suction the infant's mouth frequently with a rigid tonsil tip
catheter.
Correct Answer: B
Rationale: To prevent the infant from scratching or pulling at the
facial sutures, soft elbow restraints must be applied. They allow
movement of the shoulders but prevent the hands from reaching
the face. They must be removed periodically to assess skin
integrity and neurovascular status.
8. A nurse is caring for a client who is in active labor and has a
continuous fetal heart rate monitor attached. The nurse observes a
pattern of fetal heart rate decelerations that begin after the peak of
a uterine contraction and return to baseline well after the
contraction has ended. Which of the following actions should the
nurse take?
A. Elevate the head of the client's bed to a high-Fowler's position.
B. Turn the client onto their left side and apply high-flow
oxygen via a nonrebreather mask.
C. Request a prescription to increase the oxytocin infusion rate.
D. Instruct the client to perform deep valsalva bearing-down
maneuvers.
Correct Answer: B
Rationale: This pattern describes late decelerations, which
indicate uteroplacental insufficiency and fetal hypoxia. The
priority nursing interventions focus on improving placental
perfusion and oxygen delivery by positioning the mother on her
left side (to relieve vena cava compression), administering
oxygen, and stopping oxytocin.
9. A nurse is preparing to administer an intramuscular injection of
iron dextran to a client who has severe iron-deficiency anemia.
Which of the following techniques should the nurse use?
A. Administer the medication deep into the gluteal muscle
using the Z-track method.
B. Inject the medication into the deltoid muscle using a 25-gauge,
5/8-inch needle.
C. Massage the injection site vigorously for 2 minutes following the
injection.