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NEW 2025 ATI RN CONCEPT-BASED LEVEL 3 AND THE NGN RETAKE EXAM QUESTIONS WITH 100% CORRECT, Exams of Nursing

Chamberlain College of NursingNursing

NEW 2025 ATI RN CONCEPT-BASED LEVEL 3 AND THE NGN RETAKE EXAM QUESTIONS WITH 100% CORRECT ANSWERS

Typology: Exams

2024/2025

Available from 03/30/2025

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NEW 2025 ATI RN CONCEPT-BASED LEVEL 3 AND
THE NGN RETAKE EXAM QUESTIONS WITH 100%
CORRECT ANSWERS
RN Concept-Based Assessment Level 3 and the NGN retake!
• Question: A 68-year-old patient with a history of congestive heart failure (CHF) presents
with shortness of breath and pitting edema in the lower extremities. What is the priority
nursing intervention?
• A) Administer prescribed diuretics.
• B) Restrict fluid intake.
• C) Position the patient in high Fowler's position.
• D) Monitor daily weight and intake/output.
Answer: C) Position the patient in high Fowler's position. (Priority action to improve
oxygenation immediately. Other interventions follow.)
• Question: A patient reports acute right lower quadrant pain, nausea, and vomiting. What
condition should the nurse suspect and assess further?
• A) Cholecystitis.
• B) Appendicitis.
• C) Diverticulitis.
• D) Peptic ulcer disease.
Answer: B) Appendicitis.
• Question: A nurse is administering potassium chloride IV to a patient with hypokalemia.
What is the most critical action?
• A) Infuse the medication rapidly to resolve symptoms quickly.
• B) Monitor the IV site for signs of infiltration.
• C) Administer the potassium via IV push for immediate effect.
• D) Mix potassium chloride with lactated Ringer's solution.
Answer: B) Monitor the IV site for signs of infiltration. (Potassium can cause severe tissue
damage if extravasation occurs.)
• Question: A patient presents with a blood glucose level of 450 mg/dL, fruity breath odor,
and rapid, deep breathing. Which condition should the nurse suspect?
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Download NEW 2025 ATI RN CONCEPT-BASED LEVEL 3 AND THE NGN RETAKE EXAM QUESTIONS WITH 100% CORRECT and more Exams Nursing in PDF only on Docsity!

NEW 2025 ATI RN CONCEPT-BASED LEVEL 3 AND

THE NGN RETAKE EXAM QUESTIONS WITH 100%

CORRECT ANSWERS

RN Concept-Based Assessment Level 3 and the NGN retake!

  • Question: A 68-year-old patient with a history of congestive heart failure (CHF) presents with shortness of breath and pitting edema in the lower extremities. What is the priority nursing intervention?
    • A) Administer prescribed diuretics.
    • B) Restrict fluid intake.
    • C) Position the patient in high Fowler's position.
    • D) Monitor daily weight and intake/output. Answer: C) Position the patient in high Fowler's position. ( Priority action to improve oxygenation immediately. Other interventions follow. )
  • Question: A patient reports acute right lower quadrant pain, nausea, and vomiting. What condition should the nurse suspect and assess further?
    • A) Cholecystitis.
    • B) Appendicitis.
    • C) Diverticulitis.
    • D) Peptic ulcer disease. Answer: B) Appendicitis.
  • Question: A nurse is administering potassium chloride IV to a patient with hypokalemia. What is the most critical action?
    • A) Infuse the medication rapidly to resolve symptoms quickly.
    • B) Monitor the IV site for signs of infiltration.
    • C) Administer the potassium via IV push for immediate effect.
    • D) Mix potassium chloride with lactated Ringer's solution. Answer: B) Monitor the IV site for signs of infiltration. ( Potassium can cause severe tissue damage if extravasation occurs. )
  • Question: A patient presents with a blood glucose level of 450 mg/dL, fruity breath odor, and rapid, deep breathing. Which condition should the nurse suspect?
  • A) Hypoglycemia.
  • B) Diabetic ketoacidosis (DKA).
  • C) Hyperosmolar hyperglycemic state (HHS).
  • D) Acute pancreatitis. Answer: B) Diabetic ketoacidosis (DKA).
  • Question: A nurse is caring for a postoperative patient who reports severe, unrelieved pain despite analgesic administration. What should the nurse do first?
  • A) Provide additional pain medication.
  • B) Perform a focused physical assessment.
  • C) Reposition the patient for comfort.
  • D) Educate the patient on relaxation techniques. Answer: B) Perform a focused physical assessment.
  • Question: A patient has been prescribed warfarin for anticoagulation therapy. Which instruction should the nurse include in the discharge teaching plan?
  • A) Avoid eating foods rich in Vitamin C.
  • B) Stop the medication if minor bruising occurs.
  • C) Avoid foods high in Vitamin K.
  • D) Take aspirin for additional pain relief. Answer: C) Avoid foods high in Vitamin K. ( Vitamin K can affect the effectiveness of warfarin. )
  • Question: When assessing a patient with increased intracranial pressure (ICP), which finding is most concerning?
  • A) Dilated pupils unresponsive to light.
  • B) Blood pressure of 140/80 mmHg.
  • C) Pulse rate of 72 bpm.
  • D) Complaint of a mild headache. Answer: A) Dilated pupils unresponsive to light. ( Sign of neurological deterioration.
  • Question: A nurse is caring for a patient with a chest tube. Which finding should be reported to the healthcare provider immediately?
  • A) Gentle bubbling in the suction control chamber.
  • B) 50 mL of drainage in the collection chamber over 8 hours.
  • C) Continuous bubbling in the water seal chamber.
  • D) Tidaling in the water seal chamber with respirations. Answer: C) Continuous bubbling in the water seal chamber. ( Indicates an air leak that requires immediate attention. )

Answer: C) Perform chest physiotherapy and postural drainage. ( Helps loosen and remove secretions from the airways. )

  • Question: A patient with hypothyroidism is being discharged with a prescription for levothyroxine. What should the nurse include in the patient education?
    • A) "Take this medication with meals to enhance absorption."
    • B) "Report any symptoms of palpitations or chest pain immediately."
    • C) "Avoid all dairy products while taking this medication."
    • D) "You may notice improvement within 24 hours of starting the medication." Answer: B) "Report any symptoms of palpitations or chest pain immediately." ( These can indicate overmedication or toxicity. )
  • Question: A patient presents with a potassium level of 2.8 mEq/L. Which clinical manifestations should the nurse anticipate?
    • A) Muscle weakness and arrhythmias.
    • B) Hyperreflexia and bradycardia.
    • C) Confusion and increased urine output.
    • D) Tetany and hypotension. Answer: A) Muscle weakness and arrhythmias. ( Hypokalemia affects muscle and cardiac function. )
  • Question: A nurse observes a coworker administering insulin without verifying the dose with a second nurse. What is the most appropriate action?
    • A) Document the incident in the patient’s medical record.
    • B) Report the coworker to hospital administration immediately.
    • C) Discuss the issue with the coworker privately.
    • D) File a formal report with the risk management department. Answer: C) Discuss the issue with the coworker privately. ( First address the concern directly and professionally. )
  • Question: A patient is receiving a blood transfusion and reports chills and low back pain 15 minutes into the infusion. What should the nurse do first?
    • A) Administer acetaminophen to reduce discomfort.
    • B) Stop the transfusion and notify the healthcare provider.
    • C) Increase the infusion rate to complete the transfusion quickly.
    • D) Assess the patient’s vital signs and monitor closely. Answer: B) Stop the transfusion and notify the healthcare provider. ( These are signs of a possible transfusion reaction. )
  • Question: A patient diagnosed with acute pancreatitis has a serum calcium level of 7. mg/dL. Which clinical sign would the nurse expect to find?
  • A) Positive Trousseau's sign.
  • B) Bradycardia.
  • C) Hyperactive deep tendon reflexes.
  • D) Flushing of the skin. Answer: A) Positive Trousseau's sign. ( Hypocalcemia is common in acute pancreatitis and leads to neuromuscular irritability. )
  • Question: The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which intervention is most important for preventing respiratory acidosis?
  • A) Encourage pursed-lip breathing.
  • B) Provide a high-flow oxygen mask.
  • C) Restrict fluid intake to avoid pulmonary edema.
  • D) Administer sedatives to promote rest. Answer: A) Encourage pursed-lip breathing. ( Helps improve ventilation and prevent CO retention. )
  • Question: A nurse is assessing a patient with an arterial ulcer. Which characteristic is most commonly associated with this type of ulcer?
  • A) Brown discoloration around the ulcer.
  • B) Irregular, shallow wound with drainage.
  • C) Pale, cool skin with little to no drainage.
  • D) Edematous skin surrounding the ulcer. Answer: C) Pale, cool skin with little to no drainage. ( Indicative of poor arterial blood supply. )
  • Question: A patient taking furosemide complains of leg cramps and weakness. What lab result should the nurse check first?
  • A) Sodium level.
  • B) Potassium level.
  • C) Calcium level.
  • D) Magnesium level. Answer: B) Potassium level. ( Furosemide can lead to hypokalemia, causing muscle cramps and weakness. )
  • Question: A nurse is administering medications to a patient with Parkinson’s disease. Which medication is expected to help with bradykinesia?
  • A) Carbidopa/Levodopa.
  • B) Benztropine.
  • C) Amantadine.
  • D) Ropinirole.
  • B) Massage the uterine fundus.
  • C) Start IV fluids to prevent hypovolemia.
  • D) Notify the healthcare provider immediately. Answer: B) Massage the uterine fundus. ( This helps contract the uterus and control bleeding. )
  • Question: A nurse is caring for a patient with a deep vein thrombosis (DVT) receiving heparin therapy. What is the most important laboratory test to monitor?
  • A) Platelet count.
  • B) Prothrombin time (PT).
  • C) International Normalized Ratio (INR).
  • D) Activated partial thromboplastin time (aPTT). Answer: D) Activated partial thromboplastin time (aPTT). ( aPTT is used to monitor the effectiveness of heparin therapy. )
  • Question: A patient with chronic heart failure is prescribed furosemide. Which assessment finding requires immediate intervention?
  • A) Blood pressure of 118/70 mmHg.
  • B) Potassium level of 2.9 mEq/L.
  • C) Heart rate of 84 bpm.
  • D) Mild dizziness upon standing. Answer: B) Potassium level of 2.9 mEq/L. ( Hypokalemia is a critical risk with diuretic use. )
  • Question: A nurse is planning care for a patient admitted with an ischemic stroke. What is the priority goal in the acute phase?
  • A) Prevent aspiration.
  • B) Maintain tissue perfusion.
  • C) Manage hypertension.
  • D) Provide patient education. Answer: B) Maintain tissue perfusion. ( Restoring and maintaining cerebral blood flow is essential. )
  • Question: A patient diagnosed with rheumatoid arthritis is receiving methotrexate. What patient teaching should the nurse provide regarding this medication?
  • A) "Increase your daily water intake to prevent kidney damage."
  • B) "Avoid sunlight to reduce the risk of photosensitivity."
  • C) "You may experience frequent episodes of hypoglycemia."
  • D) "Monitor for signs of infection and report them promptly." Answer: D) "Monitor for signs of infection and report them promptly." ( Methotrexate suppresses the immune system, increasing infection risk. )
  • Question: A nurse is assessing a patient with a suspected tension pneumothorax. Which finding would the nurse expect?
    • A) Bilateral crackles on lung auscultation.
    • B) Tracheal deviation toward the unaffected side.
    • C) Bradycardia and narrowed pulse pressure.
    • D) Symmetrical chest wall movement. Answer: B) Tracheal deviation toward the unaffected side. ( This is a hallmark sign of tension pneumothorax. )
  • Question: A patient has a stage III pressure injury on the sacrum. Which intervention is most appropriate for wound care?
    • A) Apply a hydrocolloid dressing and change it every 5–7 days.
    • B) Use a foam dressing to manage exudate and protect the wound.
    • C) Pack the wound with dry gauze to absorb moisture.
    • D) Cleanse the wound with hydrogen peroxide to prevent infection. Answer: B) Use a foam dressing to manage exudate and protect the wound. ( Foam dressings help maintain a moist environment and absorb excess drainage. )
  • Question: A nurse is caring for a patient with myasthenia gravis who is experiencing difficulty swallowing. What is the nurse’s priority intervention?
    • A) Provide small, frequent meals that are easy to chew.
    • B) Suction the patient frequently to prevent aspiration.
    • C) Administer prescribed anticholinesterase medication before meals.
    • D) Encourage the patient to rest after meals to conserve energy. Answer: C) Administer prescribed anticholinesterase medication before meals. ( This improves muscle strength, aiding in safer swallowing. )
  • Question: A patient with cirrhosis presents with an elevated ammonia level. What diet is most appropriate for this patient?
    • A) High-protein, low-fat diet.
    • B) Low-protein, high-carbohydrate diet.
    • C) Low-sodium, high-potassium diet.
    • D) High-fiber, low-calorie diet. Answer: B) Low-protein, high-carbohydrate diet. ( Minimizes ammonia production by reducing protein metabolism. )
  • Question: A patient receiving total parenteral nutrition (TPN) suddenly develops confusion, diaphoresis, and tachycardia. What complication should the nurse suspect?
    • A) Hyperglycemia.
    • B) Hypoglycemia.
    • C) Electrolyte imbalance.
  • Question: A patient with acute kidney injury (AKI) has a serum creatinine level of 6. mg/dL and a blood urea nitrogen (BUN) level of 70 mg/dL. What dietary recommendation is appropriate for this patient?
    • A) Increase dietary protein to promote healing.
    • B) Encourage foods high in potassium and phosphorus.
    • C) Limit protein intake to reduce nitrogenous waste production.
    • D) Restrict carbohydrates to reduce metabolic demands. Answer: C) Limit protein intake to reduce nitrogenous waste production. ( This helps manage azotemia in AKI. )
  • Question: A patient with a history of hypertension is being treated for hypertensive crisis. Which assessment finding is most concerning?
    • A) Blood pressure of 180/110 mmHg.
    • B) Headache rated 8/10 on a pain scale.
    • C) Change in level of consciousness.
    • D) Nausea and vomiting. Answer: C) Change in level of consciousness. ( This could indicate hypertensive encephalopathy or stroke. )
  • Question: A patient with suspected pulmonary embolism is admitted to the emergency department. What is the priority nursing action?
    • A) Start an IV line and administer prescribed fluids.
    • B) Prepare the patient for a chest x-ray.
    • C) Administer supplemental oxygen.
    • D) Place the patient in a supine position. Answer: C) Administer supplemental oxygen. ( Ensuring adequate oxygenation is the priority in this situation. )
  • Question: A nurse is caring for a patient with a history of atherosclerosis who suddenly develops chest pain and dyspnea. What is the nurse's initial action?
    • A) Notify the healthcare provider.
    • B) Administer prescribed nitroglycerin.
    • C) Obtain a 12-lead ECG.
    • D) Place the patient on continuous cardiac monitoring. Answer: B) Administer prescribed nitroglycerin. ( Relieves chest pain and improves blood flow to the heart. )
  • Question: A patient with chronic renal failure has a serum potassium level of 6.8 mEq/L. Which ECG change would the nurse expect?
    • A) Prolonged PR interval.
    • B) Flattened T wave.
  • C) Peaked T waves.
  • D) Presence of U waves. Answer: C) Peaked T waves. ( This is a hallmark sign of hyperkalemia. )
  • Question: A patient with a history of type 2 diabetes is admitted with an infected foot ulcer. Which assessment finding requires immediate intervention?
  • A) Blood glucose level of 200 mg/dL.
  • B) Warm, red, swollen foot with drainage.
  • C) Temperature of 100.8°F (38.2°C).
  • D) Pale, cool foot with diminished pulses. Answer: D) Pale, cool foot with diminished pulses. ( May indicate impaired circulation and requires immediate attention. )
  • Question: A nurse is teaching a patient about the use of an incentive spirometer following abdominal surgery. Which statement by the patient indicates understanding?
  • A) "I will use the spirometer once a day to improve lung function."
  • B) "I will inhale quickly through the spirometer to fully expand my lungs."
  • C) "I will use the spirometer 10 times every hour while awake."
  • D) "I will exhale forcefully into the spirometer to clear secretions." Answer: C) "I will use the spirometer 10 times every hour while awake." ( Frequent use helps prevent postoperative complications like atelectasis. )
  • Question: A nurse is caring for a patient with peripheral arterial disease (PAD). What is the most appropriate teaching point to include?
  • A) "Elevate your legs above the heart level while resting."
  • B) "Use compression stockings to improve circulation."
  • C) "Walk regularly, even if you experience mild pain."
  • D) "Apply warm compresses to improve blood flow." Answer: C) "Walk regularly, even if you experience mild pain." ( Walking improves circulation and helps build collateral blood flow. )
  • Question: A nurse is assessing a patient for early signs of hypoxia. Which symptom is most indicative of this condition?
  • A) Bradycardia.
  • B) Restlessness.
  • C) Cyanosis.
  • D) Hypotension. Answer: B) Restlessness. ( Early hypoxia often manifests as agitation or restlessness due to decreased oxygen to the brain. )

Answer: C) Verify the blood type and crossmatch with another nurse. ( This is critical to ensure the correct blood is given. )

  • Question: A nurse is assessing a patient with dehydration. Which laboratory result is most concerning?
    • A) Hematocrit of 55%.
    • B) Serum sodium of 150 mEq/L.
    • C) Blood urea nitrogen (BUN) of 25 mg/dL.
    • D) Serum potassium of 3.0 mEq/L. Answer: D) Serum potassium of 3.0 mEq/L. ( Hypokalemia requires immediate intervention due to the risk of cardiac arrhythmias. )
  • Question: A nurse is caring for a patient with newly diagnosed tuberculosis. What instruction should the nurse include in the teaching plan?
    • A) "You will need to wear a surgical mask at all times."
    • B) "You must avoid contact with others until your treatment is complete."
    • C) "You will need to take your medications for at least 6–12 months."
    • D) "You should have follow-up chest x-rays every week during treatment." Answer: C) "You will need to take your medications for at least 6–12 months." ( This duration is necessary to effectively treat TB. )
  • Question: A patient with systemic lupus erythematosus (SLE) reports increased fatigue and joint pain. What is the nurse's priority assessment?
    • A) Check for signs of infection.
    • B) Assess for skin rashes.
    • C) Monitor for changes in blood pressure.
    • D) Evaluate dietary intake for proper nutrition. Answer: A) Check for signs of infection. ( SLE patients are immunocompromised and at higher risk for infection, which can exacerbate symptoms. )
  • Question: A patient with type 1 diabetes is experiencing diaphoresis, tremors, and confusion. What is the nurse's priority intervention?
    • A) Check the patient’s blood glucose level.
    • B) Administer a fast-acting carbohydrate.
    • C) Notify the healthcare provider immediately.
    • D) Prepare to administer glucagon intramuscularly. Answer: A) Check the patient’s blood glucose level. ( Confirm hypoglycemia before proceeding with treatment. )
  • Question: A nurse is caring for a patient receiving enoxaparin for deep vein thrombosis (DVT) prevention. Which statement by the patient requires further teaching?
  • A) "I will inject this medication into my abdomen."
  • B) "I will avoid taking over-the-counter aspirin."
  • C) "I will massage the injection site to improve absorption."
  • D) "I will rotate the injection sites regularly." Answer: C) "I will massage the injection site to improve absorption." ( Massaging the site can lead to bruising or irritation. )
  • Question: A nurse is monitoring a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding is most concerning?
  • A) Serum sodium level of 125 mEq/L.
  • B) Weight gain of 2 pounds over 24 hours.
  • C) Reports of headache and confusion.
  • D) Urine output of 50 mL over 3 hours. Answer: C) Reports of headache and confusion. ( These are symptoms of hyponatremia and cerebral edema. )
  • Question: A patient receiving chemotherapy is at risk for mucositis. What is the best nursing intervention to minimize discomfort?
  • A) Encourage the patient to drink citrus juices frequently.
  • B) Instruct the patient to rinse the mouth with a saltwater solution.
  • C) Apply an anesthetic gel before meals.
  • D) Provide mouthwash containing alcohol to clean the oral cavity. Answer: B) Instruct the patient to rinse the mouth with a saltwater solution. ( Saltwater rinses can soothe irritation and promote healing. )
  • Question: A nurse is assessing a patient with increased intracranial pressure (ICP). Which finding requires immediate intervention?
  • A) Blood pressure of 160/90 mmHg.
  • B) Unilateral pupil dilation and non-reactivity to light.
  • C) Pulse rate of 58 bpm.
  • D) Reports of a mild headache. Answer: B) Unilateral pupil dilation and non-reactivity to light. ( This can indicate brain herniation and needs urgent attention. )
  • Question: A patient with severe anemia reports fatigue and dizziness. What is the nurse's priority intervention?
  • A) Encourage the patient to engage in light physical activity.
  • B) Monitor hemoglobin and hematocrit levels closely.
  • C) Administer prescribed oxygen therapy.
  • D) Provide iron-rich foods to improve anemia.
  • C) Increase the oxygen flow rate.
  • D) Perform a complete physical assessment. Answer: B) Administer prescribed morphine to relieve pain. ( Morphine also reduces cardiac workload and oxygen demand. )
  • Question: A nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about effective breathing techniques. Which instruction should the nurse include?
  • A) "Inhale deeply and hold your breath for 10 seconds."
  • B) "Use pursed-lip breathing during periods of exertion."
  • C) "Breathe rapidly to increase oxygen intake."
  • D) "Lie flat to relax your diaphragm." Answer: B) "Use pursed-lip breathing during periods of exertion." ( This technique improves ventilation and prevents air trapping. )
  • Question: A patient with hypothyroidism is prescribed levothyroxine. Which finding indicates a therapeutic response to the medication?
  • A) Increased heart rate and improved energy levels.
  • B) Weight gain and decreased appetite.
  • C) Cold intolerance and dry skin.
  • D) Bradycardia and constipation. Answer: A) Increased heart rate and improved energy levels. ( These are signs that thyroid hormone levels are normalizing. )
  • Question: A nurse is caring for a patient with a suspected spinal cord injury at C7. Which assessment finding requires immediate intervention?
  • A) Inability to move lower extremities.
  • B) Shallow respirations and reduced oxygen saturation.
  • C) Loss of sensation in the upper extremities.
  • D) Presence of reflexes in the lower extremities. Answer: B) Shallow respirations and reduced oxygen saturation. ( Respiratory compromise is a critical concern with higher spinal cord injuries. )
  • Question: A nurse is monitoring a patient receiving magnesium sulfate for severe preeclampsia. Which finding requires immediate intervention?
  • A) Respiratory rate of 10 breaths per minute.
  • B) Serum magnesium level of 4 mg/dL.
  • C) Decreased deep tendon reflexes.
  • D) Reports of mild nausea. Answer: A) Respiratory rate of 10 breaths per minute. ( A rate below 12 bpm suggests magnesium toxicity and requires urgent action. )
  • Question: A patient with hyperparathyroidism has a serum calcium level of 13.2 mg/dL. What is the nurse's priority intervention?
    • A) Encourage increased fluid intake.
    • B) Administer calcium supplements as prescribed.
    • C) Restrict physical activity to prevent bone fractures.
    • D) Provide a diet high in vitamin D. Answer: A) Encourage increased fluid intake. ( This helps reduce the risk of kidney stones and promotes calcium excretion. )
  • Question: A nurse is caring for a patient with a thoracic spinal cord injury. Which finding requires immediate intervention?
    • A) Loss of bladder control.
    • B) Heart rate of 52 bpm.
    • C) Blood pressure of 82/48 mmHg.
    • D) Spasticity in the lower extremities. Answer: C) Blood pressure of 82/48 mmHg. ( Hypotension may indicate neurogenic shock and requires urgent attention. )
  • Question: A patient receiving a continuous IV infusion of regular insulin for diabetic ketoacidosis has a blood glucose level of 240 mg/dL. What action should the nurse take next?
    • A) Administer a bolus of insulin.
    • B) Discontinue the insulin infusion immediately.
    • C) Add dextrose to the IV solution.
    • D) Reduce the infusion rate and monitor potassium levels. Answer: C) Add dextrose to the IV solution. ( When blood glucose approaches 200– 250 mg/dL, dextrose is added to prevent hypoglycemia while continuing ketoacidosis treatment. )
  • Question: A nurse is teaching a patient with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which statement by the patient indicates correct understanding?
    • A) "I should lie down for 30 minutes after meals to aid digestion."
    • B) "I need to avoid caffeine, alcohol, and spicy foods."
    • C) "I will drink a glass of milk before bed to reduce symptoms."
    • D) "I should eat three large meals a day to limit acid production." Answer: B) "I need to avoid caffeine, alcohol, and spicy foods." ( These can exacerbate GERD symptoms. )
  • Question: A patient is receiving thrombolytic therapy for an acute ischemic stroke. Which assessment finding requires the nurse to notify the healthcare provider immediately?
    • A) Blood pressure of 170/100 mmHg.
    • B) Mild headache.
    • C) Presence of hematuria.
  • A) Tachycardia.
  • B) Hypotension.
  • C) Diarrhea.
  • D) Increased salivation. Answer: B) Hypotension. ( Orthostatic hypotension is a common side effect of carbidopa- levodopa. )
  • Question: A nurse is caring for a patient with a suspected pulmonary embolism (PE). Which diagnostic test should the nurse anticipate will be ordered to confirm the diagnosis?
  • A) Chest x-ray.
  • B) D-dimer test.
  • C) Ventilation-perfusion (V/Q) scan.
  • D) Arterial blood gases (ABGs). Answer: C) Ventilation-perfusion (V/Q) scan. ( This test identifies ventilation and perfusion mismatches indicative of PE. )
  • Question: A nurse is assessing a patient with chronic heart failure. Which assessment finding requires immediate action?
  • A) Weight gain of 2 kg (4.4 lbs) in 3 days.
  • B) Bilateral 2+ pitting edema in the ankles.
  • C) Respiratory rate of 28 breaths per minute with crackles.
  • D) Fatigue and reduced tolerance to activity. Answer: C) Respiratory rate of 28 breaths per minute with crackles. ( This indicates possible pulmonary edema, which is a medical emergency. )
  • Question: A patient with cirrhosis is at risk for hepatic encephalopathy. Which dietary recommendation is most appropriate for this condition?
  • A) High-protein diet to promote healing.
  • B) Low-protein diet to reduce ammonia levels.
  • C) High-fat diet to provide energy.
  • D) High-sodium diet to improve hydration. Answer: B) Low-protein diet to reduce ammonia levels. ( Protein metabolism produces ammonia, which can exacerbate hepatic encephalopathy. )
  • Question: A nurse is caring for a postoperative patient with a Jackson-Pratt (JP) drain. Which observation requires immediate intervention?
  • A) Drain is compressed and secured to the gown.
  • B) Bright red drainage of 100 mL in the first hour.
  • C) Serosanguineous drainage of 30 mL in 8 hours.
  • D) No drainage noted 24 hours after surgery.

Answer: B) Bright red drainage of 100 mL in the first hour. ( This may indicate active bleeding and requires immediate attention. )

  • Question: A patient with pneumonia is receiving oxygen therapy via nasal cannula. What is the most important nursing action?
    • A) Increase the flow rate to 6 L/min if the patient reports shortness of breath.
    • B) Encourage the patient to breathe through the mouth instead of the nose.
    • C) Assess the patient's oxygen saturation level regularly.
    • D) Humidify the oxygen to prevent nasal dryness. Answer: C) Assess the patient's oxygen saturation level regularly. ( This ensures the therapy is effective and helps identify any need for adjustment. )
  • Question: A patient with diabetic neuropathy reports burning and tingling sensations in their feet. Which medication does the nurse anticipate the healthcare provider will prescribe?
    • A) Metformin.
    • B) Gabapentin.
    • C) Furosemide.
    • D) Lisinopril. Answer: B) Gabapentin. ( This medication is commonly used to treat neuropathic pain. )
  • Question: A patient with sepsis is receiving aggressive IV fluid therapy. Which assessment finding indicates that the treatment is effective?
    • A) Heart rate of 110 bpm.
    • B) Blood pressure of 90/50 mmHg.
    • C) Urine output of 40 mL/hr.
    • D) Capillary refill time of 5 seconds. Answer: C) Urine output of 40 mL/hr. ( This shows adequate kidney perfusion and improved circulation. )
  • Question: A nurse is caring for a patient with acute pancreatitis. Which intervention should the nurse include in the plan of care?
    • A) Encourage a high-protein, low-fat diet.
    • B) Place the patient in a supine position.
    • C) Administer prescribed opioid analgesics for pain relief.
    • D) Provide clear liquids to maintain hydration. Answer: C) Administer prescribed opioid analgesics for pain relief. ( Pain management is a priority in acute pancreatitis. )
  • Question: A patient with hyperthyroidism is experiencing tachycardia, irritability, and a high fever. What condition should the nurse suspect?
    • A) Thyroid storm.