NURS 5366 Module 5 –Verified Questions and Correct answers solutions
A+ grade 2025_2026
1. Which of the following is the most important nursing intervention for a patient
✅
experiencing acute pain?
Answer: B. Administering prescribed analgesics on time
Elaboration:
● Rationale: Acute pain requires prompt intervention to prevent escalation and associated
complications such as increased heart rate, blood pressure, and anxiety. Timely
analgesic administration ensures patient comfort, promotes mobility, and prevents the
physiological stress response.
● Clinical context: Non-pharmacologic interventions (positioning, relaxation techniques)
support pain relief but are insufficient alone for acute pain. The nurse should follow the
prescribed pain management plan and reassess pain after administration.
2. A patient with chronic heart failure reports increasing shortness of breath. Which
✅
nursing action is priority?
Answer: A. Assess lung sounds
Elaboration:
● Rationale: Dyspnea in CHF can indicate fluid overload, pulmonary edema, or worsening
cardiac function. Assessing lung sounds helps detect crackles, wheezes, or other
abnormal findings, which guide immediate interventions.
● Clinical context: Interventions such as fluid restriction or medication adjustment depend
on the assessment findings. Vital signs and oxygen saturation are important but come
after a focused assessment of lung sounds in this scenario.
✅
3. Which lab value indicates a patient is at risk for infection?
Answer: B. WBC 22,000/mm³
,Elaboration:
● Rationale: Leukocytosis (WBC >11,000/mm³) often signals infection or inflammation. A
WBC of 22,000 is significantly elevated, suggesting an acute infectious process.
● Clinical context: Other labs (hemoglobin, platelets, sodium) are within normal limits and
do not indicate infection. The nurse should assess for infection sources and notify the
provider.
4. A patient with diabetes has a fasting glucose of 250 mg/dL. What is the nurse’s best
✅
action?
Answer: A. Administer insulin as prescribed
Elaboration:
● Rationale: Hyperglycemia (>126 mg/dL fasting) requires intervention to prevent acute
complications such as diabetic ketoacidosis (DKA). Administering insulin per the
provider’s orders helps normalize glucose levels.
● Clinical context: Encouraging fluids may help but is secondary. Reassessing without
treatment risks further hyperglycemia. Monitoring and patient education about glucose
control are also important.
5. Which intervention is most effective in preventing pressure ulcers in immobile
✅
patients?
Answer: B. Repositioning every 2 hours
Elaboration:
● Rationale: Pressure ulcers develop from prolonged pressure that impedes blood flow.
Regular repositioning relieves pressure on bony prominences, maintaining tissue
perfusion and preventing breakdown.
● Clinical context: Moisturizing and pillows help with comfort but do not prevent ulcers
alone. Massage may cause tissue damage, especially over bony areas.
✅
6. A patient is on heparin therapy. Which lab value should the nurse monitor?
Answer: C. aPTT
Elaboration:
, ● Rationale: Heparin prolongs the intrinsic pathway of coagulation, monitored via
activated partial thromboplastin time (aPTT). The therapeutic range is typically 1.5–2.5
times the control value.
● Clinical context: PT and INR monitor warfarin therapy. Platelets are monitored for
heparin-induced thrombocytopenia (HIT), but aPTT is the key parameter for dosing
adjustments.
✅
7. Which symptom is an early sign of hypoxia?
Answer: B. Restlessness
Elaboration:
● Rationale: Early hypoxia often presents as restlessness, agitation, or confusion due to
reduced oxygen delivery to the brain. Late signs include cyanosis, bradycardia, or
hypotension.
● Clinical context: Nurses should identify early hypoxia to prevent progression.
Interventions include oxygen therapy, positioning, and treating underlying causes.
8. Which nursing action is priority for a patient receiving a blood transfusion who
✅
develops shortness of breath and hypotension?
Answer: C. Stop the transfusion and notify provider
Elaboration:
● Rationale: These symptoms indicate a potentially life-threatening transfusion reaction.
Immediate cessation prevents further exposure to the incompatible blood.
● Clinical context: After stopping, the nurse should maintain IV access with normal
saline, monitor vitals, and follow institutional protocols for transfusion reactions.
✅
9. Which patient is at highest risk for developing deep vein thrombosis (DVT)?
Answer: B. Elderly post-op orthopedic patient
Elaboration:
● Rationale: Risk factors for DVT include immobility, surgery (especially orthopedic),
advanced age, obesity, and history of clotting disorders.
● Clinical context: Preventive measures include early ambulation, anticoagulants as
prescribed, compression devices, and patient education on signs of DVT.
A+ grade 2025_2026
1. Which of the following is the most important nursing intervention for a patient
✅
experiencing acute pain?
Answer: B. Administering prescribed analgesics on time
Elaboration:
● Rationale: Acute pain requires prompt intervention to prevent escalation and associated
complications such as increased heart rate, blood pressure, and anxiety. Timely
analgesic administration ensures patient comfort, promotes mobility, and prevents the
physiological stress response.
● Clinical context: Non-pharmacologic interventions (positioning, relaxation techniques)
support pain relief but are insufficient alone for acute pain. The nurse should follow the
prescribed pain management plan and reassess pain after administration.
2. A patient with chronic heart failure reports increasing shortness of breath. Which
✅
nursing action is priority?
Answer: A. Assess lung sounds
Elaboration:
● Rationale: Dyspnea in CHF can indicate fluid overload, pulmonary edema, or worsening
cardiac function. Assessing lung sounds helps detect crackles, wheezes, or other
abnormal findings, which guide immediate interventions.
● Clinical context: Interventions such as fluid restriction or medication adjustment depend
on the assessment findings. Vital signs and oxygen saturation are important but come
after a focused assessment of lung sounds in this scenario.
✅
3. Which lab value indicates a patient is at risk for infection?
Answer: B. WBC 22,000/mm³
,Elaboration:
● Rationale: Leukocytosis (WBC >11,000/mm³) often signals infection or inflammation. A
WBC of 22,000 is significantly elevated, suggesting an acute infectious process.
● Clinical context: Other labs (hemoglobin, platelets, sodium) are within normal limits and
do not indicate infection. The nurse should assess for infection sources and notify the
provider.
4. A patient with diabetes has a fasting glucose of 250 mg/dL. What is the nurse’s best
✅
action?
Answer: A. Administer insulin as prescribed
Elaboration:
● Rationale: Hyperglycemia (>126 mg/dL fasting) requires intervention to prevent acute
complications such as diabetic ketoacidosis (DKA). Administering insulin per the
provider’s orders helps normalize glucose levels.
● Clinical context: Encouraging fluids may help but is secondary. Reassessing without
treatment risks further hyperglycemia. Monitoring and patient education about glucose
control are also important.
5. Which intervention is most effective in preventing pressure ulcers in immobile
✅
patients?
Answer: B. Repositioning every 2 hours
Elaboration:
● Rationale: Pressure ulcers develop from prolonged pressure that impedes blood flow.
Regular repositioning relieves pressure on bony prominences, maintaining tissue
perfusion and preventing breakdown.
● Clinical context: Moisturizing and pillows help with comfort but do not prevent ulcers
alone. Massage may cause tissue damage, especially over bony areas.
✅
6. A patient is on heparin therapy. Which lab value should the nurse monitor?
Answer: C. aPTT
Elaboration:
, ● Rationale: Heparin prolongs the intrinsic pathway of coagulation, monitored via
activated partial thromboplastin time (aPTT). The therapeutic range is typically 1.5–2.5
times the control value.
● Clinical context: PT and INR monitor warfarin therapy. Platelets are monitored for
heparin-induced thrombocytopenia (HIT), but aPTT is the key parameter for dosing
adjustments.
✅
7. Which symptom is an early sign of hypoxia?
Answer: B. Restlessness
Elaboration:
● Rationale: Early hypoxia often presents as restlessness, agitation, or confusion due to
reduced oxygen delivery to the brain. Late signs include cyanosis, bradycardia, or
hypotension.
● Clinical context: Nurses should identify early hypoxia to prevent progression.
Interventions include oxygen therapy, positioning, and treating underlying causes.
8. Which nursing action is priority for a patient receiving a blood transfusion who
✅
develops shortness of breath and hypotension?
Answer: C. Stop the transfusion and notify provider
Elaboration:
● Rationale: These symptoms indicate a potentially life-threatening transfusion reaction.
Immediate cessation prevents further exposure to the incompatible blood.
● Clinical context: After stopping, the nurse should maintain IV access with normal
saline, monitor vitals, and follow institutional protocols for transfusion reactions.
✅
9. Which patient is at highest risk for developing deep vein thrombosis (DVT)?
Answer: B. Elderly post-op orthopedic patient
Elaboration:
● Rationale: Risk factors for DVT include immobility, surgery (especially orthopedic),
advanced age, obesity, and history of clotting disorders.
● Clinical context: Preventive measures include early ambulation, anticoagulants as
prescribed, compression devices, and patient education on signs of DVT.
