Detailed Explanations – Latest Update | Already Graded A+
Question 1
A practical nurse is caring for a 72-year-old client admitted with community-
acquired pneumonia. During assessment, the client suddenly becomes
restless, confused, and reports difficulty breathing. Oxygen saturation has
decreased from 96% to 86% on room air.
What is the nurse's priority action?
A. Encourage the client to drink fluids.
B. Administer oxygen as prescribed.
C. Assist the client to ambulate.
D. Document the assessment findings.
Correct Answer: B. Administer oxygen as prescribed.
Explanation:
Airway and breathing always take priority. The client's confusion,
restlessness, and low oxygen saturation indicate worsening hypoxia. The
nurse should immediately administer oxygen according to the prescription
while continuing to assess and notify the healthcare provider. Documentation
and hydration are important but are secondary to restoring oxygenation.
Question 2
A client with type 2 diabetes reports dizziness, sweating, trembling, and
hunger shortly before lunch.
Which nursing action is most appropriate?
A. Administer the scheduled insulin.
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,B. Check the client's blood glucose level immediately.
C. Encourage the client to exercise.
D. Restrict oral fluids.
Correct Answer: B. Check the client's blood glucose level immediately.
Explanation:
These symptoms are classic signs of hypoglycemia. The nurse should first
confirm the blood glucose level, then treat hypoglycemia according to
protocol, such as providing 15 g of fast-acting carbohydrates if the client is
conscious. Administering insulin could worsen the condition.
Question 3
A nurse is teaching a client with hypertension about lifestyle modifications.
Which client statement indicates the need for additional teaching?
A. "I will reduce the amount of salt in my diet."
B. "I will stop smoking."
C. "I only need to take my medication when I feel sick."
D. "I will monitor my blood pressure regularly."
Correct Answer: C. "I only need to take my medication when I feel sick."
Explanation:
Hypertension is often asymptomatic. Antihypertensive medications should be
taken exactly as prescribed, regardless of symptoms. Skipping doses increases
the risk of stroke, myocardial infarction, and kidney damage.
Question 4
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,A client who underwent abdominal surgery reports severe pain rated 8/10
despite receiving prescribed analgesics one hour ago.
What should the nurse do first?
A. Reassess the pain thoroughly.
B. Tell the client to wait another hour.
C. Encourage deep breathing only.
D. Document the pain score.
Correct Answer: A. Reassess the pain thoroughly.
Explanation:
Pain assessment is an ongoing process. The nurse should evaluate the pain's
location, intensity, quality, duration, and associated findings before
determining the next intervention or contacting the healthcare provider.
Question 5
A nurse is caring for a client receiving intravenous antibiotics. The IV site
becomes swollen, cool, and painful.
Which complication is most likely occurring?
A. Phlebitis
B. Infiltration
C. Infection
D. Hematoma
Correct Answer: B. Infiltration
Explanation:
Infiltration occurs when IV fluid leaks into surrounding tissue. Signs include
swelling, coolness, discomfort, and slowed infusion. The nurse should
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, discontinue the IV, elevate the extremity, and restart the IV at another site if
needed.
Question 6
A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen therapy.
Which oxygen saturation target is generally appropriate for this client?
A. 100%
B. 98–100%
C. 88–92%
D. Below 85%
Correct Answer: C. 88–92%
Explanation:
Many clients with COPD require controlled oxygen therapy. Maintaining
oxygen saturation between 88% and 92% helps improve oxygenation while
reducing the risk of carbon dioxide retention in susceptible individuals.
Question 7
The nurse is caring for a client receiving warfarin therapy.
Which laboratory value is most important to monitor?
A. White blood cell count
B. Platelet count
C. INR
D. Blood glucose
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