CORRECT ANSWERS (VERIFIED ANSWERS) Q&A
2027 |INSTANT DOWNLOAD PDF
1. A nurse is caring for a client admitted with acute left-sided
heart failure. Which assessment finding requires immediate
intervention?
A. Bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Crackles throughout both lung fields with oxygen saturation
of 84%
D. Jugular vein distention
Correct Answer: C. Crackles throughout both lung fields with
oxygen saturation of 84%
Rationale: Pulmonary edema causing severe hypoxemia is a
life-threatening complication requiring immediate intervention.
Edema, weight gain, and jugular vein distention indicate fluid
overload but are less immediately critical.
2. A client with chronic kidney disease has a serum potassium
level of 6.5 mEq/L. Which action should the nurse take first?
A. Restrict fluids
B. Obtain a 12-lead ECG
,C. Encourage oral fluids
D. Administer iron supplements
Correct Answer: B. Obtain a 12-lead ECG
Rationale: Hyperkalemia can cause fatal cardiac dysrhythmias.
The nurse should first assess cardiac effects before
implementing additional interventions.
3. A nurse is caring for a client with chronic obstructive
pulmonary disease (COPD). Which oxygen prescription is most
appropriate?
A. 100% oxygen via nonrebreather mask
B. 10 L/min via simple mask
C. 1–2 L/min via nasal cannula
D. 15 L/min via face tent
Correct Answer: C. 1–2 L/min via nasal cannula
Rationale: Clients with COPD often require low-flow oxygen to
maintain adequate oxygenation while minimizing the risk of
suppressing respiratory drive.
4. A client develops sudden chest pain and shortness of breath
after surgery. Which complication should the nurse suspect
first?
A. Atelectasis
B. Pulmonary embolism
,C. Pneumonia
D. Heartburn
Correct Answer: B. Pulmonary embolism
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia,
and hypoxemia are classic findings of pulmonary embolism.
5. Which laboratory finding is most concerning in a client
receiving chemotherapy?
A. Hemoglobin 11.2 g/dL
B. Platelets 170,000/mm³
C. WBC 1,200/mm³
D. Sodium 138 mEq/L
Correct Answer: C. WBC 1,200/mm³
Rationale: Severe leukopenia places the client at high risk for
life-threatening infection.
6. A nurse is caring for a client experiencing hypoglycemia.
Which finding should the nurse expect?
A. Dry skin
B. Bradycardia
C. Confusion and diaphoresis
D. Fruity breath odor
Correct Answer: C. Confusion and diaphoresis
, Rationale: Hypoglycemia commonly causes sweating,
confusion, tremors, tachycardia, and irritability due to
sympathetic nervous system activation.
7. Which client should the nurse assess first?
A. Client with a temperature of 100.4°F (38°C) after surgery
B. Client reporting pain rated 7/10 after medication
C. Client with new onset confusion and oxygen saturation of
86%
D. Client requesting assistance to the bathroom
Correct Answer: C. Client with new onset confusion and oxygen
saturation of 86%
Rationale: Airway and breathing take priority. Hypoxia
accompanied by altered mental status requires immediate
assessment.
8. A client receiving intravenous heparin develops bleeding
gums. Which laboratory result should the nurse review?
A. INR
B. aPTT
C. Hemoglobin A1C
D. Creatinine
Correct Answer: B. aPTT