2025 ACTUAL EXAM 500 QUESTIONS AND CORRECT DETAILED
ANSWERS (100% VERIFIED ANSWERS) |ALREADY GRADED A+
1. A nurse is caring for a client who is 2 days post-operative following an
abdominal hysterectomy. The client reports pain as 6 on a 0-10 scale.
Which of the following actions should the nurse take first?
A) Administer the prescribed opioid analgesic.
B) Reposition the client for comfort.
C) Assess the incision site for redness and swelling.
D) Document the client's pain rating.
Correct Answer: A) Administer the prescribed opioid analgesic.
Rationale: According to the nursing process and client advocacy, the
priority is to alleviate the client's reported pain. Administering the
prescribed analgesic is the most direct and immediate intervention to
address acute discomfort. While repositioning, assessment, and
documentation are important, addressing the client's immediate
comfort takes precedence.
2. A nurse is assessing a client with a new diagnosis of heart failure.
Which of the following findings would indicate fluid volume overload
and requires immediate intervention?
A) Dry mucous membranes and increased urine output.
B) Hypotension and decreased central venous pressure.
C) Jugular venous distension (JVD) and crackles in the lungs.
D) Peripheral pulses that are weak and thready.
, Correct Answer: C) Jugular venous distension (JVD) and crackles in
the lungs.
Rationale: JVD is a sign of increased right-sided heart pressure, and
crackles (pulmonary edema) indicate fluid accumulation in the lungs
due to left-sided heart failure. Both are classic signs of severe fluid
volume overload, compromising cardiac and respiratory function, and
requiring immediate intervention (e.g., diuretics, oxygen).
3. A nurse is preparing to administer insulin to a client with diabetes. The
client's blood glucose is 48 mg/dL. The client is awake, alert, and able
to swallow. Which of the following actions should the nurse take first?
A) Administer 1 mg glucagon IM.
B) Offer 15g of a simple carbohydrate (e.g., 4 oz orange juice).
C) Administer IV Dextrose 50% (D50W).
D) Document the blood glucose reading.
Correct Answer: B) Offer 15g of a simple carbohydrate (e.g., 4 oz
orange juice).
Rationale: For an awake, alert, and cooperative client experiencing
hypoglycemia, the immediate intervention is to administer 15g of a
fast-acting simple carbohydrate orally to rapidly raise blood glucose.
Glucagon or IV D50W are reserved for unresponsive clients or when
oral intake is not safe.
4. A nurse is providing discharge teaching to a parent about sudden
infant death syndrome (SIDS) prevention. Which of the following
, statements by the parent indicates a need for further teaching?
A) "I should place my baby to sleep on their back."
B) "I will put soft toys and blankets in the crib with my baby."
C) "I will use a firm mattress for my baby's crib."
D) "I will avoid smoking around my baby."
Correct Answer: B) "I will put soft toys and blankets in the crib with
my baby."
Rationale: Soft objects, loose bedding, pillows, and bumper pads
should be removed from the crib to reduce the risk of SIDS, as they can
lead to suffocation or rebreathing of exhaled air. Infants should be
placed on their backs on a firm mattress in a smoke-free environment.
5. A nurse is caring for a client who is exhibiting aggressive behavior.
After ensuring the safety of the client and others, which of the
following is the next priority for the nurse?
A) Administer a PRN sedative medication.
B) Document the incident in the client's chart.
C) Attempt to de-escalate the situation verbally.
D) Apply restraints to the client.
Correct Answer: C) Attempt to de-escalate the situation verbally.
Rationale: After ensuring immediate physical safety (e.g., removing
other clients, creating space), the next step is typically verbal de-
escalation techniques. This is the least restrictive intervention to
attempt before considering pharmacological or physical restraints.
, 6. A nurse is assessing a client with a history of deep vein thrombosis
(DVT). The client suddenly reports sharp chest pain, dyspnea, and a
feeling of impending doom. The nurse should suspect which of the
following and prepare for immediate intervention?
A) Myocardial infarction.
B) Pneumonia.
C) Pulmonary embolism.
D) Anxiety attack.
Correct Answer: C) Pulmonary embolism.
Rationale: Sudden onset of sharp chest pain, dyspnea, and a sense of
impending doom, especially in a client with a DVT history, are classic
and critical symptoms of a pulmonary embolism (PE), requiring
immediate medical intervention (e.g., oxygen, anticoagulants,
thrombolytics).
7. A nurse is caring for a client who had a stroke and has right-sided
hemiparesis. The nurse observes the client attempting to feed
themselves but struggling to grasp the fork. Which of the following
interventions should the nurse implement to promote independence?
A) Feed the client to ensure adequate nutrition.
B) Provide a fork with a built-up handle.
C) Instruct the client to use their left hand.
D) Encourage the client to wait for a family member to assist.
Correct Answer: B) Provide a fork with a built-up handle.