(2025/2026) – Verified Questions and
Correct Answers | Latest Actual Exam |
Updated Edition | Graded A+
1. A client with newly diagnosed type 2 diabetes asks why they must test their capillary
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blood glucose at different times each day. Which response by the nurse is best?
A. “Testing at different times helps catch highs and lows that you would otherwise miss.”
B. “It is required so your doctor can see every variation in your sugars.”
C. “You only need to test at different times if you feel unwell.”
D. “Random testing is more accurate than fasting testing.”
Rationale: Testing at different times (fasting, pre-meal, post-prandial) identifies patterns of
hyper- and hypoglycemia to guide treatment.
2. A client is receiving a continuous IV infusion of normal saline at 125 mL/hr. Which
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assessment finding requires the nurse’s immediate action?
A. Urine output 25 mL in 2 hours.
B. Lungs clear bilaterally.
C. Radial pulse 76 and regular.
D. Peripheral IV site without redness or swelling.
Rationale: Urine output <30 mL/hr indicates inadequate renal perfusion or fluid retention and
needs immediate evaluation.
3. Which action best demonstrates the nursing process step of evaluation?
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A. Administering a prescribed antibiotic on schedule.
B. Comparing the client’s current pain score to the pain goal after medication.
C. Setting a goal for the client to ambulate 50 feet.
D. Documenting the client’s initial intake and output.
Rationale: Evaluation compares outcomes to goals (e.g., pain score after intervention).
4. The nurse is teaching a client about isolation precautions for C. difficile. Which
statement by the client indicates correct understanding?
A. “I will wear a mask whenever staff are in the room.”
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B. “I will use hand sanitizer after leaving the bathroom.”
C. “I will wash my hands with soap and water after using the toilet.”
D. “I do not need to change bed linen more often than usual.”
Rationale: C. difficile spores are not killed effectively by alcohol hand rub — soap and water
handwashing is required.
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5. A client reports new-onset chest pain. Which action should the nurse take first?
A. Obtain a 12-lead ECG.
B. Give a PRN acetaminophen.
C. Call the client’s family.
D. Ask about the client’s food intake.
Rationale: For chest pain, immediate ECG and assessment for acute coronary syndrome are
priorities.
6. When administering a large-volume enema to an adult, which position is safest for the
client?
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A. Supine with head flat.
B. Left lateral (Sims’) position with knees slightly flexed.
C. Right lateral with legs extended.
D. High Fowler’s position.
Rationale: Left lateral Sims’ position facilitates flow into the sigmoid colon and is standard for
enemas.
7. A nurse is preparing to give an IM injection. Which action reduces the risk of
intravascular injection?
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A. Use the smallest gauge needle available.
B. Aspirate before injecting (pull back on plunger) when indicated by facility policy.
C. Inject rapidly to reduce discomfort.
D. Give in a site with visible varicosities.
Rationale: Aspiration can help detect intravascular placement when recommended by policy
(note: facility practice may vary).
8. A client with COPD has an oxygen prescription of 2 L/min by nasal cannula. The family
says the client wants oxygen increased because of shortness of breath. What should the
nurse do first?
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A. Increase oxygen to 4 L/min as requested.
B. Assess respiratory status and oxygen saturation.
C. Explain that oxygen cannot be increased without a physician’s order.
D. Encourage coughing and deep breathing only.
Rationale: Always assess respiratory status and SpO₂ before changing oxygen; adjustments
require clinical evaluation.
9. Which entry is most appropriate for the nurse’s progress note after performing wound
care?
A. “Wound cleaned; dressing changed.”
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B. “Wound edges approximated, no drainage; dry sterile dressing applied; client tolerated
procedure well.”
C. “Dressing applied per orders.”
D. “Wound looks better.”
Rationale: Documentation should be specific: condition, interventions, client tolerance.
, 10. The nurse is teaching a client about taking a newly prescribed iron tablet. Which
instruction is correct?
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A. “Take the iron with a glass of milk to decrease nausea.”
B. “Take with orange juice or vitamin C to enhance absorption.”
C. “Take at bedtime only.”
D. “If you miss a dose, double the next dose.”
Rationale: Vitamin C increases iron absorption; milk impairs it. Never double doses.
11. A client is post-op day 1 after abdominal surgery and has a prescription for incentive
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spirometry every hour while awake. The most important reason for this intervention is to:
A. Prevent atelectasis and improve lung expansion.
B. Strengthen abdominal muscles.
C. Decrease the need for analgesics.
D. Lower pulse and blood pressure.
Rationale: Incentive spirometry promotes lung expansion and reduces atelectasis risk.
12. A nurse is caring for a confused older adult at risk for falls. Which intervention is
most effective to reduce fall risk?
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A. Keep the bedside table out of reach.
B. Put the bed in the lowest position and place the call light within reach.
C. Use physical restraints when the client attempts to get out of bed.
D. Turn off the room lights at night to encourage sleep.
Rationale: Bed low, call light reachable, and frequent toileting/checks reduce fall risk; restraints
increase harm.
13. A client with heart failure is prescribed furosemide 40 mg PO daily. Which lab value
should the nurse monitor closely?
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A. Blood glucose.
B. Potassium level.
C. Hemoglobin A1c.
D. Platelet count.
Rationale: Loop diuretics cause potassium loss; monitor K⁺ and replace if needed.
14. A client refuses morning care and asks that the nurse come back later. What is the
nurse’s best response?
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A. “You must do morning care now.”
B. “I’ll come back in an hour to help when you’re ready.”
C. “If you don’t bathe, I’ll document it.”
D. “No one refuses morning care.”
Rationale: Respect client autonomy and offer to return; document refusal if it persists.
15. A nurse finds a small fire at the client’s bedside. What is the correct sequence of
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actions (RACE)?
A. Rescue, Alarm, Confine, Extinguish.
B. Rescue, Confine, Alarm, Extinguish.