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1.
A nurse is caring for a client admitted with diabetic ketoacidosis. Which finding indicates that
treatment is effective?
A. Blood glucose 140 mg/dL
B. Urine negative for ketones
C. Respiratory rate 12/min
D. Potassium level 3.2 mEq/L
Correct Answer: B
Rationale:
Resolution of ketoacidosis is best indicated by the absence of ketones, reflecting correction of fat
breakdown and metabolic acidosis. Glucose levels may normalize before acidosis fully resolves,
making ketone clearance the most reliable indicator of effective treatment.
2.
A nurse is caring for a client with acute coronary syndrome. Which medication should be
administered first?
A. Morphine
B. Nitroglycerin
C. Aspirin
D. Metoprolol
Correct Answer: C
,Rationale:
Aspirin inhibits platelet aggregation, reducing clot progression and myocardial damage. Early
administration significantly decreases mortality in acute coronary syndrome.
3.
A nurse is assessing a client with suspected hypovolemia. Which finding supports this diagnosis?
A. Bounding pulses
B. Dry mucous membranes
C. Hypertension
D. Jugular vein distention
Correct Answer: B
Rationale:
Dry mucous membranes indicate decreased intravascular volume and dehydration, commonly
seen in hypovolemia.
4.
A nurse is caring for a client with SIADH. Which lab value is expected?
A. Hypernatremia
B. Hyponatremia
C. Hyperkalemia
D. Elevated glucose
Correct Answer: B
Rationale:
Excess antidiuretic hormone causes water retention, diluting serum sodium and leading to
hyponatremia.
5.
A nurse is caring for a client with a bowel obstruction. Which assessment finding is most
concerning?
A. Abdominal distention
B. High-pitched bowel sounds
C. Absence of bowel sounds
D. Nausea
Correct Answer: C
,Rationale:
Absent bowel sounds suggest paralytic ileus or worsening obstruction, increasing risk for
perforation and sepsis.
6.
A nurse is caring for a client with end-stage renal disease. Which dietary instruction is most
important?
A. Increase protein intake
B. Limit phosphorus intake
C. Increase potassium intake
D. Increase sodium intake
Correct Answer: B
Rationale:
Impaired phosphorus excretion leads to bone disease and vascular calcification, making
phosphorus restriction critical.
7.
A nurse is caring for a client with pulmonary embolism. Which symptom is most characteristic?
A. Gradual onset dyspnea
B. Sudden shortness of breath
C. Productive cough
D. Bradycardia
Correct Answer: B
Rationale:
Pulmonary embolism presents with sudden onset dyspnea due to abrupt obstruction of
pulmonary blood flow.
8.
A nurse is caring for a client receiving amphotericin B. Which lab value must be closely
monitored?
A. Sodium
B. Calcium
C. Potassium
D. Glucose
, Correct Answer: C
Rationale:
Amphotericin B can cause nephrotoxicity and potassium wasting, increasing risk for life-
threatening hypokalemia.
9.
A nurse is caring for a client with hypothyroidism. Which assessment finding is expected?
A. Heat intolerance
B. Weight loss
C. Bradycardia
D. Hyperreflexia
Correct Answer: C
Rationale:
Decreased thyroid hormone slows metabolism, leading to reduced heart rate and cardiac output.
10.
A nurse is caring for a client with acute pericarditis. Which symptom is most specific?
A. Chest pain relieved by leaning forward
B. Crushing substernal pain
C. Pain radiating to left arm
D. Pain worsened by exertion
Correct Answer: A
Rationale:
Pericardial inflammation causes pain that improves when the heart is positioned away from the
pericardium.
11.
A nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding requires
immediate intervention?
A. Ascending weakness
B. Facial paralysis
C. Decreased vital capacity
D. Tingling in extremities