2026/2027 | 200 Questions and Verified Answers | Complete
Q&A Guide | A+ Graded
1. A nurse receives handoff report on four patients. Which patient should the nurse see first?
A) Patient with pneumonia, oxygen saturation 91% on 3L nasal cannula
B) Patient with pancreatitis reporting pain 8/10
C) Patient who had a stroke 4 hours ago with new slurred speech
D) Patient with a fractured tibia requesting pain medication
Answer: C
Rationale: New neurological change in a poststroke patient suggests possible progression or
complication (e.g., hemorrhage, edema). Sudden change in neurological status is a priority over stable
vital signs (A), pain (B and D), and routine requests.
2. A patient with type 1 diabetes mellitus is found unconscious. Which action should the nurse take
first?
A) Administer glucagon IM
B) Check blood glucose
C) Give orange juice orally
D) Start an IV with dextrose 50%
Answer: B
Rationale: Check blood glucose first to determine if the cause is hypoglycemia or hyperglycemia.
Treating without knowing glucose level can be harmful. Glucagon (A) and D50 (D) are given after
confirmation of hypoglycemia. Never give oral fluids to an unconscious patient (C).
,3. A nurse is assessing a client with a history of chronic heart failure who presents with increasing
shortness of breath and bilateral lower extremity edema. Which assessment finding requires immediate
intervention?
A) Weight gain of 1 pound over 24 hours
B) Mild dyspnea on exertion
C) Crackles auscultated in both lung bases
D) Oxygen saturation of 84% on room air
Answer: D
Rationale: An oxygen saturation of 84% indicates significant hypoxemia and requires immediate
intervention to prevent respiratory failure. While crackles and mild weight gain are concerning, they are
less urgent compared to critically low oxygen levels.
4. A nurse is caring for a postoperative client receiving morphine via PCA. Which finding indicates the
need for immediate action?
A) Respiratory rate of 8 breaths per minute
B) Pain rating of 6 out of 10
C) Sedation score of 2 (slightly drowsy)
D) Blood pressure of 130/78 mmHg
Answer: A
Rationale: A respiratory rate of 8 indicates respiratory depression, a serious adverse effect of opioids,
requiring immediate intervention such as stopping the PCA and administering naloxone if necessary.
5. A nurse is teaching a client newly diagnosed with type 1 diabetes mellitus about insulin
administration. Which statement indicates correct understanding?
,A) "I will rotate injection sites within the same anatomical area."
B) "I should massage the injection site after administration."
C) "I can reuse insulin syringes multiple times."
D) "I will inject insulin into muscle for faster absorption."
Answer: A
Rationale: Rotating sites within the same anatomical region promotes consistent insulin absorption and
prevents lipodystrophy. Massaging the site (B) can alter absorption; syringes should not be reused (C);
insulin should be injected subcutaneously, not into muscle (D).
6. A nurse is assessing a patient with suspected heart failure. Which finding should the nurse report
immediately to the healthcare provider?
A) Mild ankle edema
B) Oxygen saturation of 92%
C) Crackles in bilateral lung bases
D) Weight gain of 2 pounds over 2 days
Answer: C
Rationale: Crackles in bilateral lung bases indicate pulmonary edema, a serious complication of heart
failure that requires immediate intervention. This finding suggests fluid accumulation in the lungs and
potential respiratory compromise. Mild ankle edema, oxygen saturation of 92%, and 2pound weight gain
are concerning but not immediately lifethreatening.
7. A patient receiving morphine sulfate for pain management has a respiratory rate of 8 breaths per
minute. What is the nurse's priority action?
A) Administer naloxone (Narcan)
B) Increase the oxygen flow rate
, C) Stimulate the patient to breathe
D) Document the finding and continue monitoring
Answer: A
Rationale: Opioidinduced respiratory depression with a respiratory rate of 8 breaths/min is a
lifethreatening emergency. Naloxone is an opioid antagonist that reverses respiratory depression
immediately. While stimulating the patient and increasing oxygen are supportive measures, they do not
address the underlying opioid toxicity.
8. Which ethical principle is demonstrated when a nurse respects a patient's decision to refuse blood
transfusion despite medical recommendations?
A) Justice
B) Beneficence
C) Autonomy
D) Accountability
Answer: C
Rationale: Autonomy is the right of patients to make informed decisions about their own care, even
when those decisions conflict with medical recommendations.
9. A charge nurse is making assignments on a medicalsurgical unit. Which client should be assigned to
the most experienced RN?
A) A client 2 days postappendectomy requesting pain medication
B) A newly admitted client with chest pain and unstable vital signs
C) A client on day 3 following total hip replacement
D) A client with a UTI receiving oral antibiotics