Exam Retake 2025/2026 – Questions
with Verified Rationalized Answers
Question 1: A nurse is caring for a client with acute myocardial infarction. What is the
priority intervention?
A. Administer aspirin 325 mg
B. Obtain 12-lead ECG
C. Start oxygen at 4 L/min
D. Prepare for thrombolytics
Correct Answer: B. Obtain 12-lead ECG
Rationale: ECG confirms STEMI for reperfusion within 10 minutes (AHA).
Question 2: A client with COPD exacerbation has RR 28, SpO2 88%. Priority?
A. Administer albuterol nebulizer
B. Start oxygen at 2 L/min NC
C. Both A and B
D. Prepare for intubation
Correct Answer: C. Both A and B
Rationale: Bronchodilator relieves bronchospasm; titrated O2 maintains SpO2 88-92% (GOLD).
Question 3: Post-op client with urinary retention. Priority?
A. Catheterize
B. Increase fluids
C. Administer bethanechol
D. Assess for obstruction
Correct Answer: D. Assess for obstruction
Rationale: Rule out kinks or clots before intervention (AHA safety).
Question 4: Client with type 1 diabetes has BS 350 mg/dL. Priority?
A. Administer insulin
B. Give fluids
C. Both
D. Monitor only
, Correct Answer: B. Give fluids
Rationale: Rehydration first in DKA to avoid hypokalemia (ADA).
Question 5: A nurse assesses a client with suspected DVT. Priority?
A. Homan's sign
B. D-dimer
C. Both
D. Doppler US
Correct Answer: D. Doppler US
Rationale: Gold standard for DVT diagnosis (AHA).
Question 6: Client with heart failure on furosemide has K+ 3.2 mEq/L. Priority?
A. Give K+ supplement
B. Monitor ECG
C. Both
D. Restrict K+
Correct Answer: C. Both
Rationale: Hypokalemia risks arrhythmias; supplement and monitor ECG (AHA).
Question 7: A client with pneumonia has SpO2 90% on room air. Priority?
A. High-flow O2
B. BiPAP
C. Assess airway
D. Labs
Correct Answer: C. Assess airway
Rationale: Ensure patent airway before oxygenation (AHA ABCs).
Question 8: Post-appendectomy client has fever 102°F day 2. Priority?
A. Antibiotics
B. Wound culture
C. Both
D. Observe
Correct Answer: B. Wound culture
Rationale: Guides targeted antibiotic therapy (AHA).