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2025/2026 /Latest Update/Instant
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1. A nurse is caring for a client with a nasogastric tube connected to low intermittent
suction. The client reports abdominal cramping. What is the priority action?
A. Increase the suction
B. Administer an antacid
C. Check for tube patency
D. Notify the provider
Answer: C
Rationale: Abdominal cramping may indicate a blockage or kinking of the NG tube. Ensuring
tube patency is the priority before other interventions.
2. A client with congestive heart failure is prescribed furosemide. Which assessment
finding requires immediate action?
A. Weight gain of 1 lb in 24 hours
B. Potassium level of 2.8 mEq/L
C. Mild ankle edema
D. Increased urine output
Answer: B
Rationale: A potassium level of 2.8 mEq/L indicates hypokalemia, which can cause life-
threatening cardiac arrhythmias. This is an immediate concern.
3. A nurse is teaching a client with diabetes about hypoglycemia. Which statement
indicates understanding?
A. “I will eat a candy bar if my blood sugar is low.”
B. “I should exercise if my blood sugar is 50 mg/dL.”
, C. “I will check my blood sugar every 6 hours.”
D. “I should skip meals if I feel shaky.”
Answer: A
Rationale: Rapidly absorbed carbohydrates like a candy bar help quickly raise blood glucose
during hypoglycemia.
4. The nurse is preparing to administer digoxin. Which assessment finding requires
withholding the medication?
A. Apical pulse 60 bpm
B. Blood pressure 110/70 mmHg
C. Apical pulse 48 bpm
D. Respiratory rate 18/min
Answer: C
Rationale: Digoxin can slow the heart rate. An apical pulse below 60 bpm in adults requires
withholding the drug and notifying the provider.
5. A client is admitted with dehydration. Which IV fluid is most appropriate initially?
A. 0.9% NaCl (normal saline)
B. 5% dextrose in water
C. Lactated Ringer’s
D. 0.45% NaCl
Answer: A
Rationale: Normal saline is isotonic and expands extracellular fluid volume, making it
appropriate for initial fluid resuscitation in dehydration.
6. Which action by the nurse is appropriate when caring for a client with an ileostomy?
A. Apply a large diaper over the stoma
B. Irrigate the stoma daily
C. Empty the pouch when it is 1/3 to 1/2 full
D. Use soap and water to clean around the stoma
Answer: C
Rationale: Emptying the pouch when it is partially full prevents leakage and skin irritation.
Soap can irritate the stoma, and daily irrigation is usually not required.
7. A nurse is teaching a client about the use of albuterol for asthma. Which statement
indicates correct understanding?
A. “I will use it daily even if I feel fine.”
B. “I should take it before exercise if I have exercise-induced asthma.”
C. “I can take unlimited doses if I feel short of breath.”
D. “It works best if I take it at night.”
, Answer: B
Rationale: Albuterol is a short-acting bronchodilator used as needed for symptoms and
before exercise to prevent bronchospasm.
8. Which finding indicates fluid overload in a client receiving IV therapy?
A. Weight loss of 2 lbs in 24 hours
B. Crackles in the lungs
C. Dry mucous membranes
D. Decreased urine output
Answer: B
Rationale: Crackles indicate pulmonary edema, a sign of fluid overload.
9. A client is prescribed morphine for pain. Which intervention should the nurse
implement first?
A. Assess bowel sounds
B. Monitor respiratory rate
C. Offer food
D. Assist with ambulation
Answer: B
Rationale: Morphine can cause respiratory depression. Monitoring respiratory rate is the
priority assessment before administration.
10. Which is the most appropriate action for a nurse caring for a client with a latex
allergy?
A. Keep latex gloves available in the room
B. Use non-latex gloves and equipment
C. Administer antihistamines prophylactically
D. Avoid only balloon exposure
Answer: B
Rationale: Clients with latex allergy should have non-latex equipment to prevent allergic
reactions, which can be severe.
11. A client is on a low-sodium diet. Which food choice indicates understanding?
A. Canned soup
B. Fresh fruit
C. Processed cheese
D. Pickles
Answer: B
Rationale: Fresh fruit is naturally low in sodium and appropriate for a low-sodium diet.
12. Which is the priority nursing action for a client with chest pain?
A. Obtain vital signs