PRACTICE QUESTIONS WITH VERIFIED
ANSWERS & RATIONALES | 2026–2027 EDITION |
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A patient with congestive heart failure has 2+ pitting edema in the lower extremities. The nurse
should:
A. Encourage ambulation
B. Elevate the legs and monitor daily weight
C. Restrict fluids only
D. Apply heat packs
Rationale: Elevation and daily weight monitoring help manage fluid overload.
A patient receiving morphine reports difficulty breathing. The nurse’s first action is:
A. Call family
B. Document the event
C. Assess airway and respiratory status
D. Encourage coughing
Rationale: Respiratory depression is a life-threatening opioid side effect.
A nurse is preparing to administer an IM injection. The recommended needle length for an adult
is:
A. 1/2 inch
B. 3 inches
C. 1–1.5 inches
D. 2.5 inches
Rationale: Standard adult IM injections typically require 1–1.5 inch needles.
A patient with type 1 diabetes reports nausea and vomiting with high blood glucose. Which is
most concerning?
A. Hypoglycemia
B. Diabetic ketoacidosis (DKA)
C. Hyperlipidemia
D. Hypertension
Rationale: Nausea, vomiting, and hyperglycemia in type 1 diabetes indicate risk for DKA.
A patient is post-op day 1 following abdominal surgery. Which intervention is priority?
A. Administer pain meds
B. Assess bowel sounds and monitor for ileus
C. Assist with ambulation only
D. Change wound dressing
Rationale: Early recognition of post-op ileus is critical to prevent complications.
, Which lab value indicates a possible infection?
A. Hemoglobin 14 g/dL
B. WBC 15,000/mm³
C. Platelets 250,000/mm³
D. Sodium 140 mEq/L
Rationale: Elevated WBC indicates potential infection.
A patient reports shortness of breath and wheezing after using a new inhaler. The nurse should:
A. Encourage continued use
B. Assess for allergic reaction or bronchospasm
C. Document only
D. Administer a sedative
Rationale: Respiratory distress could indicate an adverse reaction.
A patient is receiving IV potassium chloride. Which precaution is essential?
A. Administer rapidly
B. Dilute and administer slowly
C. Give undiluted
D. Administer bolus
Rationale: Rapid IV potassium can cause cardiac arrhythmias; slow infusion is critical.
A patient is confused and wandering at night. Which intervention is most appropriate?
A. Physical restraints immediately
B. Ignore to avoid distress
C. Use sitter and environment safety measures
D. Administer sedative without order
Rationale: Safety and least-restrictive interventions are priority; restraints are last resort.
A patient with hypertension is prescribed hydrochlorothiazide. Which statement shows
understanding?
A. “I will stop the medication if I feel dizzy.”
B. “I will take it only when my blood pressure is high.”
C. “I will monitor my weight and blood pressure daily.”
D. “I will double the dose if I forget one.”
Rationale: Daily monitoring ensures efficacy and early detection of side effects like
hypokalemia.
A patient with COPD is receiving oxygen at 2 L/min via nasal cannula. The nurse notes
confusion and restlessness. The most appropriate action is:
A. Increase oxygen to 5 L/min
B. Assess for CO₂ retention and notify provider
C. Encourage deep breathing only
D. Place in supine position
Rationale: Patients with COPD may retain CO₂; confusion may indicate hypercapnia.