PN 4006 FINAL EXAMINATION COMPLETE
QUESTIONS WITH 100% VERIFIED ANSWERS
AND DETAILED RATIONALES
1. A nurse is caring for a client with pneumonia who has a fever of 102.2°F (39°C).
Which intervention should the nurse implement first?
A. Administer antipyretics as ordered.
B. (Correct) Remove excess blankets and provide tepid sponging.
C. Increase oral fluid intake.
D. Notify the healthcare provider.
Rationale: First-line fever management is nonpharmacological cooling to reduce
metabolic demand; antipyretics follow if needed.
2. A client with chronic kidney disease has a potassium level of 6.5 mEq/L. Which
ECG change does the nurse anticipate?
A. U waves
B. (Correct) Tall peaked T waves
C. ST segment depression
D. Prolonged PR interval
Rationale: Hyperkalemia (K > 5.5) typically causes tall, peaked T waves; U waves
suggest hypokalemia.
3. A nurse is teaching a client about digoxin. Which statement indicates the client
needs further teaching?
A. “I will check my pulse before taking the medication.”
B. “I will report vision changes like yellow-green halos.”
,C. “I can take antacids at the same time as my digoxin.”
D. (Correct) “I will take an extra dose if I miss one.”
Rationale: Taking extra digoxin increases toxicity risk; antacids reduce absorption
and should be spaced apart.
4. A patient post-myocardial infarction is prescribed aspirin 81 mg daily. What is
the primary purpose?
A. Pain relief
B. (Correct) Prevent platelet aggregation
C. Reduce fever
D. Lower blood pressure
Rationale: Low-dose aspirin inhibits thromboxane A2, reducing clot formation in
coronary arteries.
5. A nurse delegates vital signs to an unlicensed assistive personnel (UAP) for a
stable client. Which action by the UAP requires the nurse to intervene?
A. Repeats blood pressure reading in same arm.
B. (Correct) Documents respiratory rate as 16 without counting.
C. Uses adult cuff for an obese client.
D. Takes oral temperature after client drinks cold water.
Rationale: Estimating respiratory rate without counting is falsifying data; UAP
must count for 30–60 seconds.
6. A client is started on sertraline for depression. The nurse instructs the client to
report which adverse effect immediately?
A. Dry mouth
B. Insomnia
C. (Correct) Suicidal thoughts
D. Mild nausea
,Rationale: Antidepressants carry black box warning for increased suicidality in
young adults, especially early in treatment.
7. A toddler is admitted with dehydration. Which finding indicates severe
dehydration?
A. Capillary refill 2 seconds
B. (Correct) Sunken fontanelles and absent tears
C. Moist mucous membranes
D. Heart rate 110 bpm
Rationale: Sunken fontanelles, absent tears, and delayed capillary refill (>3 sec)
indicate severe dehydration in infants/toddlers.
8. A nurse is preparing to administer insulin lispro. When should the nurse give
this insulin?
A. 30 minutes before a meal
B. (Correct) Immediately before a meal (0–15 minutes)
C. 2 hours after a meal
D. At bedtime only
Rationale: Lispro is rapid-acting; onset ~15 minutes, so it must be given just
before or immediately after meals to prevent postprandial hyperglycemia.
9. A client with schizophrenia tells the nurse, “The FBI is poisoning my water.”
What is the therapeutic response?
A. “That’s not true, you’re safe here.”
B. (Correct) “It must be frightening to believe that.”
C. “Why do you think the FBI would do that?”
D. “Let’s talk about something else.”
Rationale: Validate the feeling without reinforcing the delusion; arguing or
challenging increases anxiety.
, 10. A nurse is caring for a client with a chest tube. The drainage system
accidentally falls over and cracks. What is the nurse’s priority action?
A. Clamp the chest tube immediately.
B. (Correct) Place the end of the tube in sterile water.
C. Call the provider.
D. Replace the system without additional steps.
Rationale: Placing tube end in sterile water maintains water seal and prevents air
from entering pleural space until new system is set up.
11. A postpartum client reports a large gush of blood and a firm, boggy fundus.
What should the nurse do first?
A. Notify the provider.
B. (Correct) Massage the fundus.
C. Administer oxytocin.
D. Measure the peripads.
Rationale: Boggy fundus with bleeding indicates uterine atony; fundal massage is
immediate first-line intervention.
12. A client on heparin therapy has a partial thromboplastin time (PTT) of 110
seconds (normal ~25–35). Which antidote should the nurse anticipate?
A. Vitamin K
B. (Correct) Protamine sulfate
C. Naloxone
D. Flumazenil
Rationale: Protamine sulfate reverses heparin; vitamin K reverses warfarin.
QUESTIONS WITH 100% VERIFIED ANSWERS
AND DETAILED RATIONALES
1. A nurse is caring for a client with pneumonia who has a fever of 102.2°F (39°C).
Which intervention should the nurse implement first?
A. Administer antipyretics as ordered.
B. (Correct) Remove excess blankets and provide tepid sponging.
C. Increase oral fluid intake.
D. Notify the healthcare provider.
Rationale: First-line fever management is nonpharmacological cooling to reduce
metabolic demand; antipyretics follow if needed.
2. A client with chronic kidney disease has a potassium level of 6.5 mEq/L. Which
ECG change does the nurse anticipate?
A. U waves
B. (Correct) Tall peaked T waves
C. ST segment depression
D. Prolonged PR interval
Rationale: Hyperkalemia (K > 5.5) typically causes tall, peaked T waves; U waves
suggest hypokalemia.
3. A nurse is teaching a client about digoxin. Which statement indicates the client
needs further teaching?
A. “I will check my pulse before taking the medication.”
B. “I will report vision changes like yellow-green halos.”
,C. “I can take antacids at the same time as my digoxin.”
D. (Correct) “I will take an extra dose if I miss one.”
Rationale: Taking extra digoxin increases toxicity risk; antacids reduce absorption
and should be spaced apart.
4. A patient post-myocardial infarction is prescribed aspirin 81 mg daily. What is
the primary purpose?
A. Pain relief
B. (Correct) Prevent platelet aggregation
C. Reduce fever
D. Lower blood pressure
Rationale: Low-dose aspirin inhibits thromboxane A2, reducing clot formation in
coronary arteries.
5. A nurse delegates vital signs to an unlicensed assistive personnel (UAP) for a
stable client. Which action by the UAP requires the nurse to intervene?
A. Repeats blood pressure reading in same arm.
B. (Correct) Documents respiratory rate as 16 without counting.
C. Uses adult cuff for an obese client.
D. Takes oral temperature after client drinks cold water.
Rationale: Estimating respiratory rate without counting is falsifying data; UAP
must count for 30–60 seconds.
6. A client is started on sertraline for depression. The nurse instructs the client to
report which adverse effect immediately?
A. Dry mouth
B. Insomnia
C. (Correct) Suicidal thoughts
D. Mild nausea
,Rationale: Antidepressants carry black box warning for increased suicidality in
young adults, especially early in treatment.
7. A toddler is admitted with dehydration. Which finding indicates severe
dehydration?
A. Capillary refill 2 seconds
B. (Correct) Sunken fontanelles and absent tears
C. Moist mucous membranes
D. Heart rate 110 bpm
Rationale: Sunken fontanelles, absent tears, and delayed capillary refill (>3 sec)
indicate severe dehydration in infants/toddlers.
8. A nurse is preparing to administer insulin lispro. When should the nurse give
this insulin?
A. 30 minutes before a meal
B. (Correct) Immediately before a meal (0–15 minutes)
C. 2 hours after a meal
D. At bedtime only
Rationale: Lispro is rapid-acting; onset ~15 minutes, so it must be given just
before or immediately after meals to prevent postprandial hyperglycemia.
9. A client with schizophrenia tells the nurse, “The FBI is poisoning my water.”
What is the therapeutic response?
A. “That’s not true, you’re safe here.”
B. (Correct) “It must be frightening to believe that.”
C. “Why do you think the FBI would do that?”
D. “Let’s talk about something else.”
Rationale: Validate the feeling without reinforcing the delusion; arguing or
challenging increases anxiety.
, 10. A nurse is caring for a client with a chest tube. The drainage system
accidentally falls over and cracks. What is the nurse’s priority action?
A. Clamp the chest tube immediately.
B. (Correct) Place the end of the tube in sterile water.
C. Call the provider.
D. Replace the system without additional steps.
Rationale: Placing tube end in sterile water maintains water seal and prevents air
from entering pleural space until new system is set up.
11. A postpartum client reports a large gush of blood and a firm, boggy fundus.
What should the nurse do first?
A. Notify the provider.
B. (Correct) Massage the fundus.
C. Administer oxytocin.
D. Measure the peripads.
Rationale: Boggy fundus with bleeding indicates uterine atony; fundal massage is
immediate first-line intervention.
12. A client on heparin therapy has a partial thromboplastin time (PTT) of 110
seconds (normal ~25–35). Which antidote should the nurse anticipate?
A. Vitamin K
B. (Correct) Protamine sulfate
C. Naloxone
D. Flumazenil
Rationale: Protamine sulfate reverses heparin; vitamin K reverses warfarin.
