test Questions And Correct Answers
(Verified Answers) Plus Rationales
2025 Q&A | Instant Download
1. A nurse is caring for a client with chronic heart failure. Which assessment
finding should the nurse report immediately?
a. Bilateral ankle edema
b. Weight gain of 2 pounds overnight
c. Shortness of breath at rest
d. Fatigue after activity
Shortness of breath at rest indicates worsening heart failure and possible
pulmonary edema, requiring immediate intervention.
2. A client receiving IV heparin has an aPTT of 120 seconds. What action
should the nurse take?
a. Continue the infusion as ordered
b. Increase the infusion rate
c. Stop the infusion and notify the provider
d. Administer an additional bolus
A therapeutic aPTT is usually 1.5–2.5 times normal (25–35 sec); 120 is
dangerously high and indicates risk for bleeding.
,3. A patient with cirrhosis develops ascites. Which diet should the nurse
anticipate?
a. High sodium
b. Low sodium
c. High potassium
d. Low protein
Sodium restriction helps reduce fluid retention and control ascites in liver
disease.
4. A nurse prepares to administer digoxin. Which finding should make the
nurse hold the medication?
a. BP 110/70 mmHg
b. Respiratory rate 18/min
c. Apical pulse 50 bpm
d. Temperature 98.6°F
Digoxin should be held if the heart rate is below 60 bpm due to risk of
bradycardia.
5. A client with COPD is receiving oxygen at 4 L/min via nasal cannula. Which
finding requires intervention?
a. The client is lethargic and difficult to arouse
b. The client has a productive cough
c. The client’s skin is dry
d. The client is using pursed-lip breathing
High oxygen flow can suppress respiratory drive in COPD clients, leading to
CO₂ retention and lethargy.
,6. A nurse teaches a client about warfarin. Which statement indicates
understanding?
a. “I can eat large amounts of spinach.”
b. “I will take aspirin for headaches.”
c. “I will use an electric razor to shave.”
d. “I can double my dose if I miss one.”
Using an electric razor reduces the risk of bleeding, which is important for
clients on anticoagulants.
7. Which client is at greatest risk for developing a pressure injury?
a. A 45-year-old postoperative client
b. A 35-year-old ambulatory client
c. An 80-year-old client with a hip fracture
d. A 60-year-old receiving physical therapy
Older adults with limited mobility are at high risk due to impaired
circulation and skin integrity.
8. A nurse assesses a client with hypokalemia. Which finding is most
concerning?
a. Muscle cramps
b. Fatigue
c. Constipation
d. Irregular heartbeat
Cardiac dysrhythmias are life-threatening complications of low potassium
levels.
, 9. A client with type 1 diabetes is confused and diaphoretic. What should the
nurse do first?
a. Call the healthcare provider
b. Administer insulin
c. Give 15 grams of carbohydrates
d. Obtain a urine ketone test
Confusion and sweating suggest hypoglycemia; immediate glucose
administration is priority.
10.A client with tuberculosis is on airborne precautions. Which PPE should the
nurse use?
a. Gown and gloves only
b. Surgical mask
c. N95 respirator
d. Face shield only
An N95 respirator is required for airborne precautions to filter TB bacteria.
11.A nurse is caring for a client who just had a thyroidectomy. Which
assessment is priority?
a. Level of consciousness
b. Blood pressure
c. Incision site drainage
d. Respiratory rate and airway patency
Airway obstruction from swelling or hematoma is the most serious
complication post-thyroidectomy.