COMPLETE 200 REAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
WITH RATIONALES ALREADY GRADED A+
1. A nurse is caring for a client receiving a blood transfusion. The client
reports chills, fever, and back pain. What is the nurse's priority action?
A) Monitor vital signs
B) Stop the transfusion immediately
C) Administer antipyretics
D) Continue transfusion at a slower rate
Answer B: Stop the transfusion immediately
Rationale: These are classic signs of an acute hemolytic transfusion reaction,
which can be life-threatening. The immediate priority is to stop the transfusion to
prevent further hemolysis.
2. A nurse is assessing a client who has just had a fall. Which assessment
finding requires immediate intervention?
A) The patient reports pain in the right hip and cannot bear weight
B) The patient has a small laceration on the forearm
C) The patient is alert but anxious about falling again
,D) The patient's blood pressure is 130/80 mmHg
Answer A: The patient reports pain in the right hip and cannot bear weight
Rationale: Inability to bear weight and localized pain after a fall suggests a
possible fracture or dislocation, which requires immediate evaluation.
3. A nurse is calculating intake for a client over 8 hours. The client consumed:
120 mL coffee, 180 mL broth, 240 mL water, and 90 mL ice chips. What is the
total intake in mL?
A) 570
B) 615
C) 630
D) 660
Answer B: 615
Rationale: Ice chips are counted as half their volume (90/2 = 45). Total = 120 +
180 + 240 + 45 = 615 mL.
4. A nurse is providing discharge teaching to a client prescribed warfarin.
Which dietary instruction is most important?
A) Avoid foods high in vitamin K, such as leafy green vegetables
B) Increase intake of foods rich in vitamin C
C) Limit fluid intake to prevent fluid retention
D) Take the medication with a high-fat meal
Answer A: Avoid foods high in vitamin K, such as leafy green vegetables
,Rationale: Vitamin K antagonizes the effects of warfarin. Patients should maintain
consistent intake of vitamin K-containing foods and avoid large amounts.
5. Which position is most appropriate for a client experiencing shortness of
breath?
A) Supine
B) Prone
C) High Fowler's
D) Trendelenburg
Answer C: High Fowler's
Rationale: High Fowler's position promotes maximal lung expansion and eases
breathing.
6. A nurse is reviewing practice guidelines with a group of newly licensed
nurses. Which of the following interventions should the nurse include that is
within the RN scope of practice?
A) Insert an implanted port
B) Close laceration with sutures
C) Place an endotracheal tube
D) Initiate an enteral feeding through a gastrostomy tube
Answer D: Initiate an enteral feeding through a gastrostomy tube
, Rationale: RNs can initiate enteral feedings through gastrostomy tubes. Invasive
procedures such as port insertion, suturing, and endotracheal intubation are
typically outside the RN scope.
7. A nurse is caring for a client who reports pain. When documenting the
quality of the client's pain on an initial pain assessment, the nurse should
record which of the following?
A) "Client rates pain as 6/10"
B) "The pain is like a dull ache in my stomach"
C) "Client appears to be in pain"
D) "Pain is intermittent"
Answer B: "The pain is like a dull ache in my stomach"
Rationale: Quality of pain is a subjective description of the pain's nature.
Recording the client's exact words is best practice.
8. A nurse is teaching a client who has a new diagnosis of diabetes mellitus
about how to perform capillary blood glucose testing. Which of the following
instructions should the nurse include?
A) Wipe the finger with alcohol and test immediately while wet
B) Use a drop of blood large enough to cover the pad on the reagent strip
C) Squeeze the finger firmly to obtain enough blood
D) Use the center of the fingertip for testing