Nursing EAQs 2026 |
Essential Assessment
Questions, Answers,
Rationales &
Comprehensive Nursing
Exam Review | Complete
Ethics Study Guide
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,While taking the blood pressure of a client with Auscultatory gap
hypertension, the nurse hears the first Korotkoff sound at
128 mm Hg, then no sound is heard until the manometer is Auscultatory gap occurs when there is absence of Korotkoff sounds between the
at 110 mm Hg, and then Korotkoff sounds are heard until first and second sounds and can be as large as 40 mm Hg. Failure to lower
sounds disappear completely at 72 mm Hg. Which pressure on the sphygmomanometer slowly may lead to not hearing the initial
abnormal finding will the nurse document? Korotkoff sounds and inaccurate assessment of systolic pressure. Pulsus
paradoxus or paradoxical pulse indicates that the systolic pressure is 10 mm Hg or
Auscultatory gap more higher during expiration than on inspiration. Pulsus paradoxus is sometimes
Pulsus paradoxus noted in clients with pericardial effusions. A widened pulse pressure is documented
Widened pulse pressure when the difference between the systolic and diastolic pressures is higher than 40
Isolated systolic hypertension mm Hg. Isolated systolic hypertension would be documented when the systolic
pressure is high but the diastolic pressure is normal
A client is admitted to the emergency department with Start infusion of normal saline
reports of frequent loose, watery stools and anorexia
during the past week. Blood pressure is 90/68 mm Hg and The client's history of watery stools and anorexia suggests hypovolemia as the
pulse is 124. Which prescribed action will the nurse take cause of the hypotension and tachycardia; fluids should be rapidly infused to correct
first? hypovolemia. Blood and urine cultures are needed to determine whether the client
has a bacterial infection, but correction of the hypovolemia is a higher priority. A
Obtain blood and urine cultures retention catheter may be needed for hourly intake and output measurements, but
Start infusion of normal saline the nurse will first initiate actions to correct hypovolemia. Transfer to the intensive
Insert retention catheter care unit is appropriate, but the nurse would not wait until after the transfer to initiate
Transfer the client to intensive care unit needed interventions to correct hypovolemia
When a client with peripheral arterial disease tells the Intermittent claudication
nurse about having leg pain and weakness after walking a
short distance, how will the nurse document this Intermittent claudication is pain that results when the arterial system is unable to
information? provide adequate blood flow to the tissues in the presence of increased demands
for oxygen and nutrients during exercise; it is relieved by rest. Rest pain is not a
Rest pain response to exercise; it occurs in the extremities during rest, especially at night.
Raynaud phenomenon Raynaud phenomenon is intermittent episodes of constricted arteries and arterioles
Intermittent claudication in response to extreme cold or emotional stress, causing pallor, paresthesias, and
Phantom limb sensation pain. Phantom limb sensation is the presence of unusual sensations or pain in the
removed portion of an amputation
When the emergency department nurse is caring for a Morphine sulfate 4 mg intravenously
client with acute coronary syndrome who reports severe
crushing chest pressure, which prescribed medication is Morphine will relieve pain and decrease sympathetic nervous system stimulation
best for the nurse to administer? associated with pain. Ibuprofen will not work quickly to reduce pain. Acetaminophen
also will not be rapidly effective. Nitroglycerin is ineffective in relieving ischemic pain
Ibuprofen 650 mg orally with myocardial infarction
Acetaminophen 650 mg orally
Nitroglycerin 0.4 mg sublingually
Morphine sulfate 4 mg intravenously
Which collaborative action would be best to rehydrate an Offer frequent oral fluids for several hours.
alert client seen in the urgent care center with dehydration,
a heart rate of 100 beats/minute, and blood pressure of Usually the least invasive means possible of rehydration is used for clients needing
104/62 mm Hg? rehydration. Based on the heart rate and blood pressure, the client has mild
dehydration, and oral fluids offered over several hours will improve hydration.
Offer frequent oral fluids for several hours. Infusion of normal saline could be used, but is more invasive and has a small risk of
Administer 1 liter of normal saline over 2 hours. infection associated with the use of an intravenous catheter. Nasogastric tube use is
Give fluid and electrolytes per nasogastric tube. invasive and uncomfortable and not needed in this alert client, who can swallow
Infuse 500 mL of lactated Ringer's solution over 30 liquids. Infusion of electrolyte solutions such as lactated Ringer's solution rapidly
minutes. also is invasive and places the client at risk of infection.
When teaching an unlicensed health care worker about Support the client's arm at heart level when taking BP.
blood pressure (BP) measurement, which information will Have the client rest for 5 minutes before measuring BP.
the nurse include? Select all that apply. One, some, or all
responses may be correct. Recommendations for accurate BP measurement include having the client rest
quietly for at least 5 minutes before taking the BP and having the client's arm
Support the client's arm at heart level when taking BP. supported at heart level. Thinner clients will need a smaller BP cuff. The cuff should
Have the client rest for 5 minutes before measuring BP. be deflated at a rate of 2 to 3 mm Hg per second. Automatic BP machines may be
Choose a larger BP cuff size for thinner clients. inaccurate in clients with hypotension or who have dysrhythmias.
Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
Automatic BP machines are preferable to manually taking
BPs.
, When caring for a client who has a blood pressure of Increase circulating blood volume
80/60 mm Hg and heart rate of 120 beats/minute after a
motor vehicle accident, the nurse anticipates the need to The client's history of a motor vehicle accident and low blood pressure with
rapidly implement which type of collaborative action? tachycardia indicates likely hemorrhage and hypovolemic shock. The initial
treatment would be infusion of blood and crystalloids such as normal saline.
Increase circulating blood volume Vasopressors might be used in septic or neurogenic shock, when hypotension is
Administer arterial vasopressors caused by vasodilation. Increasing heart rate will occur as a compensatory
Stimulate increased heart rate mechanism for hypovolemia, but medications to stimulate heart rate are not
Correct electrolyte disturbances needed. There is no indication that the client has electrolyte disturbances.
A client has an open reduction and internal fixation (ORIF) Tachycardia and petechiae over the chest
of a fractured hip. The nurse monitors this client for signs
and symptoms of a fat embolism. Which client assessment Tachycardia occurs because of an impaired gas exchange; petechiae are caused
finding reflects this complication? by occlusion of small vessels within the skin. Chest pain is not a common complaint
with a fat embolism; fever may occur later. A positive Homans sign occurs with
Fever and chest pain thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation
Positive Homans sign suggests neurological dysfunction; it is not an indication of a fat embolism
Loss of sensation in the operative leg
Tachycardia and petechiae over the chest
Which physiological process causes temperature elevation Tissue necrosis and inflammation
after a client has had a myocardial infarction?
The body's inflammatory response to myocardial necrosis causes an elevation of
Tissue necrosis and inflammation temperature as well as leukocytosis within 24 to 48 hours after the event. Arterial
Thrombosis followed by thrombolysis thrombosis that causes myocardial infarction is followed by thrombolysis, but does
Sympathetic nervous system stimulation not cause elevated temperature. Sympathetic activation does commonly occur with
Infectious process of myocardial muscle cells stress associated with myocardial infarction but is not the cause of fever. Myocardial
infarction is not associated with an infectious process.
When the nurse is caring for a diabetic client with a Systolic blood pressure persistently 85 to 90 mm Hg
bacterial infection of the foot, which assessment finding
indicates a need to activate the rapid response team? A systolic blood pressure less than 90 in a client who is at risk for sepsis (such as
this client with a bacterial infection and diabetes) indicates possible sepsis and
Hypertonic bowel sounds in all 4 quadrants systemic inflammatory response syndrome (SIRS). The nurse would immediately
Blood glucose level 145 mg/dL (8.1 mmol/L) activate the rapid response team and anticipate collaborative actions such as
Client report of level 9 pain of the foot (0 to 10 scale) further diagnostic testing, massive fluid infusion, and administration of
Systolic blood pressure persistently 85 to 90 mm Hg vasoconstrictive medications. Hypotonic bowel sounds may indicate sepsis or SIRS.
Blood glucose levels higher than 140 mg/dL (7.7 mmol/L) might indicate sepsis or
SIRS in a nondiabetic client, but would not be unusual in a client with diabetes.
Level 9 out of 10 pain would require administration of analgesics, but is not as
concerning as hypotension and does not require activation of the rapid response
team
When the nurse is teaching a client with hypertension Liking the taste of table salt is learned, but it can be modified with practice
about a sodium-restricted diet, which information would be
included? The taste for salt is learned from habitual use and can be unlearned or reduced with
health improvement motivation and creative salt-free food preparation. Substitutes
Using salt-free natural seasonings can taste the same as do not taste the same as salt. Using salt substitutes containing potassium chloride
salt. may be unsafe; excessive use can produce abnormally high serum potassium
Substituting table salt with potassium chloride can be done levels. The taste for salt is learned.
freely.
Desiring the taste for salt is inherent but can be overcome
with help.
Liking the taste of table salt is learned, but it can be
modified with practice.
A client is experiencing an exacerbation of systemic lupus Techniques to reduce stress
erythematosus. To reduce the frequency of exacerbations,
what would be important for the nurse to include in the Systemic lupus erythematosus is an autoimmune disorder, and physical and
client's teaching plan? emotional stresses have been identified as contributing factors to the occurrence of
exacerbations. Although basic principles of hygiene should be performed,
Basic principles of hygiene inadequate hygiene is not known to produce exacerbations. Although measures to
Techniques to reduce stress improve nutrition should be done, nutritional status is not significantly correlated to
Measures to improve nutrition exacerbations. Knowledge of the symptoms will not decrease the occurrence of
Signs of an impending exacerbation exacerbations.
Essential Assessment
Questions, Answers,
Rationales &
Comprehensive Nursing
Exam Review | Complete
Ethics Study Guide
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,While taking the blood pressure of a client with Auscultatory gap
hypertension, the nurse hears the first Korotkoff sound at
128 mm Hg, then no sound is heard until the manometer is Auscultatory gap occurs when there is absence of Korotkoff sounds between the
at 110 mm Hg, and then Korotkoff sounds are heard until first and second sounds and can be as large as 40 mm Hg. Failure to lower
sounds disappear completely at 72 mm Hg. Which pressure on the sphygmomanometer slowly may lead to not hearing the initial
abnormal finding will the nurse document? Korotkoff sounds and inaccurate assessment of systolic pressure. Pulsus
paradoxus or paradoxical pulse indicates that the systolic pressure is 10 mm Hg or
Auscultatory gap more higher during expiration than on inspiration. Pulsus paradoxus is sometimes
Pulsus paradoxus noted in clients with pericardial effusions. A widened pulse pressure is documented
Widened pulse pressure when the difference between the systolic and diastolic pressures is higher than 40
Isolated systolic hypertension mm Hg. Isolated systolic hypertension would be documented when the systolic
pressure is high but the diastolic pressure is normal
A client is admitted to the emergency department with Start infusion of normal saline
reports of frequent loose, watery stools and anorexia
during the past week. Blood pressure is 90/68 mm Hg and The client's history of watery stools and anorexia suggests hypovolemia as the
pulse is 124. Which prescribed action will the nurse take cause of the hypotension and tachycardia; fluids should be rapidly infused to correct
first? hypovolemia. Blood and urine cultures are needed to determine whether the client
has a bacterial infection, but correction of the hypovolemia is a higher priority. A
Obtain blood and urine cultures retention catheter may be needed for hourly intake and output measurements, but
Start infusion of normal saline the nurse will first initiate actions to correct hypovolemia. Transfer to the intensive
Insert retention catheter care unit is appropriate, but the nurse would not wait until after the transfer to initiate
Transfer the client to intensive care unit needed interventions to correct hypovolemia
When a client with peripheral arterial disease tells the Intermittent claudication
nurse about having leg pain and weakness after walking a
short distance, how will the nurse document this Intermittent claudication is pain that results when the arterial system is unable to
information? provide adequate blood flow to the tissues in the presence of increased demands
for oxygen and nutrients during exercise; it is relieved by rest. Rest pain is not a
Rest pain response to exercise; it occurs in the extremities during rest, especially at night.
Raynaud phenomenon Raynaud phenomenon is intermittent episodes of constricted arteries and arterioles
Intermittent claudication in response to extreme cold or emotional stress, causing pallor, paresthesias, and
Phantom limb sensation pain. Phantom limb sensation is the presence of unusual sensations or pain in the
removed portion of an amputation
When the emergency department nurse is caring for a Morphine sulfate 4 mg intravenously
client with acute coronary syndrome who reports severe
crushing chest pressure, which prescribed medication is Morphine will relieve pain and decrease sympathetic nervous system stimulation
best for the nurse to administer? associated with pain. Ibuprofen will not work quickly to reduce pain. Acetaminophen
also will not be rapidly effective. Nitroglycerin is ineffective in relieving ischemic pain
Ibuprofen 650 mg orally with myocardial infarction
Acetaminophen 650 mg orally
Nitroglycerin 0.4 mg sublingually
Morphine sulfate 4 mg intravenously
Which collaborative action would be best to rehydrate an Offer frequent oral fluids for several hours.
alert client seen in the urgent care center with dehydration,
a heart rate of 100 beats/minute, and blood pressure of Usually the least invasive means possible of rehydration is used for clients needing
104/62 mm Hg? rehydration. Based on the heart rate and blood pressure, the client has mild
dehydration, and oral fluids offered over several hours will improve hydration.
Offer frequent oral fluids for several hours. Infusion of normal saline could be used, but is more invasive and has a small risk of
Administer 1 liter of normal saline over 2 hours. infection associated with the use of an intravenous catheter. Nasogastric tube use is
Give fluid and electrolytes per nasogastric tube. invasive and uncomfortable and not needed in this alert client, who can swallow
Infuse 500 mL of lactated Ringer's solution over 30 liquids. Infusion of electrolyte solutions such as lactated Ringer's solution rapidly
minutes. also is invasive and places the client at risk of infection.
When teaching an unlicensed health care worker about Support the client's arm at heart level when taking BP.
blood pressure (BP) measurement, which information will Have the client rest for 5 minutes before measuring BP.
the nurse include? Select all that apply. One, some, or all
responses may be correct. Recommendations for accurate BP measurement include having the client rest
quietly for at least 5 minutes before taking the BP and having the client's arm
Support the client's arm at heart level when taking BP. supported at heart level. Thinner clients will need a smaller BP cuff. The cuff should
Have the client rest for 5 minutes before measuring BP. be deflated at a rate of 2 to 3 mm Hg per second. Automatic BP machines may be
Choose a larger BP cuff size for thinner clients. inaccurate in clients with hypotension or who have dysrhythmias.
Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
Automatic BP machines are preferable to manually taking
BPs.
, When caring for a client who has a blood pressure of Increase circulating blood volume
80/60 mm Hg and heart rate of 120 beats/minute after a
motor vehicle accident, the nurse anticipates the need to The client's history of a motor vehicle accident and low blood pressure with
rapidly implement which type of collaborative action? tachycardia indicates likely hemorrhage and hypovolemic shock. The initial
treatment would be infusion of blood and crystalloids such as normal saline.
Increase circulating blood volume Vasopressors might be used in septic or neurogenic shock, when hypotension is
Administer arterial vasopressors caused by vasodilation. Increasing heart rate will occur as a compensatory
Stimulate increased heart rate mechanism for hypovolemia, but medications to stimulate heart rate are not
Correct electrolyte disturbances needed. There is no indication that the client has electrolyte disturbances.
A client has an open reduction and internal fixation (ORIF) Tachycardia and petechiae over the chest
of a fractured hip. The nurse monitors this client for signs
and symptoms of a fat embolism. Which client assessment Tachycardia occurs because of an impaired gas exchange; petechiae are caused
finding reflects this complication? by occlusion of small vessels within the skin. Chest pain is not a common complaint
with a fat embolism; fever may occur later. A positive Homans sign occurs with
Fever and chest pain thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation
Positive Homans sign suggests neurological dysfunction; it is not an indication of a fat embolism
Loss of sensation in the operative leg
Tachycardia and petechiae over the chest
Which physiological process causes temperature elevation Tissue necrosis and inflammation
after a client has had a myocardial infarction?
The body's inflammatory response to myocardial necrosis causes an elevation of
Tissue necrosis and inflammation temperature as well as leukocytosis within 24 to 48 hours after the event. Arterial
Thrombosis followed by thrombolysis thrombosis that causes myocardial infarction is followed by thrombolysis, but does
Sympathetic nervous system stimulation not cause elevated temperature. Sympathetic activation does commonly occur with
Infectious process of myocardial muscle cells stress associated with myocardial infarction but is not the cause of fever. Myocardial
infarction is not associated with an infectious process.
When the nurse is caring for a diabetic client with a Systolic blood pressure persistently 85 to 90 mm Hg
bacterial infection of the foot, which assessment finding
indicates a need to activate the rapid response team? A systolic blood pressure less than 90 in a client who is at risk for sepsis (such as
this client with a bacterial infection and diabetes) indicates possible sepsis and
Hypertonic bowel sounds in all 4 quadrants systemic inflammatory response syndrome (SIRS). The nurse would immediately
Blood glucose level 145 mg/dL (8.1 mmol/L) activate the rapid response team and anticipate collaborative actions such as
Client report of level 9 pain of the foot (0 to 10 scale) further diagnostic testing, massive fluid infusion, and administration of
Systolic blood pressure persistently 85 to 90 mm Hg vasoconstrictive medications. Hypotonic bowel sounds may indicate sepsis or SIRS.
Blood glucose levels higher than 140 mg/dL (7.7 mmol/L) might indicate sepsis or
SIRS in a nondiabetic client, but would not be unusual in a client with diabetes.
Level 9 out of 10 pain would require administration of analgesics, but is not as
concerning as hypotension and does not require activation of the rapid response
team
When the nurse is teaching a client with hypertension Liking the taste of table salt is learned, but it can be modified with practice
about a sodium-restricted diet, which information would be
included? The taste for salt is learned from habitual use and can be unlearned or reduced with
health improvement motivation and creative salt-free food preparation. Substitutes
Using salt-free natural seasonings can taste the same as do not taste the same as salt. Using salt substitutes containing potassium chloride
salt. may be unsafe; excessive use can produce abnormally high serum potassium
Substituting table salt with potassium chloride can be done levels. The taste for salt is learned.
freely.
Desiring the taste for salt is inherent but can be overcome
with help.
Liking the taste of table salt is learned, but it can be
modified with practice.
A client is experiencing an exacerbation of systemic lupus Techniques to reduce stress
erythematosus. To reduce the frequency of exacerbations,
what would be important for the nurse to include in the Systemic lupus erythematosus is an autoimmune disorder, and physical and
client's teaching plan? emotional stresses have been identified as contributing factors to the occurrence of
exacerbations. Although basic principles of hygiene should be performed,
Basic principles of hygiene inadequate hygiene is not known to produce exacerbations. Although measures to
Techniques to reduce stress improve nutrition should be done, nutritional status is not significantly correlated to
Measures to improve nutrition exacerbations. Knowledge of the symptoms will not decrease the occurrence of
Signs of an impending exacerbation exacerbations.
