STYLE PRACTICE QUESTIONS
Question 1
A nurse is caring for a client who is 2 hours post-op following a total hip
arthroplasty. Which of the following assessment findings should the nurse
report to the provider immediately?
A) Heart rate 88/min
B) Oxygen saturation 94% on room air
C) Incisional pain rated 6 on a 0–10 scale
D) New-onset confusion and restlessness
Correct Answer: D) New-onset confusion and restlessness
Rationale: New-onset confusion and restlessness in a post-op client can
indicate fat embolism syndrome, a life-threatening complication following
long-bone or hip surgery. Early recognition and prompt reporting are critical.
The other findings are within expected ranges or manageable with routine
interventions.
Question 2
A nurse is preparing to administer a blood transfusion to a client who has
anemia. Which of the following actions should the nurse take first?
A) Verify the client’s identity using two identifiers
B) Check the expiration date on the blood unit
C) Obtain baseline vital signs
D) Ensure informed consent is on the chart
Correct Answer: A) Verify the client’s identity using two identifiers
,Rationale: The first action in the nursing process is assessment, but for
transfusion safety, verifying client identity with two identifiers is the priority
to prevent a transfusion error. While all options are important, client
identification is the initial and most critical safety step.
Question 3
A nurse is assessing a client who has heart failure and is receiving
furosemide. Which of the following findings indicates the medication is
having the desired effect?
A) Decreased blood pressure
B) Increased urine output
C) Weight gain of 1 kg in 24 hours
D) Jugular venous distension
Correct Answer: B) Increased urine output
Rationale: Furosemide is a loop diuretic used to reduce fluid overload in heart
failure. The desired therapeutic effect is increased urine output, which
decreases preload and reduces symptoms such as edema and dyspnea.
Weight gain and JVD indicate worsening failure, and decreased BP is a side
effect, not the primary goal.
Question 4
A nurse is providing discharge teaching to a client who has a new diagnosis
of type 2 diabetes mellitus. Which of the following statements by the client
indicates an understanding of the teaching?
A) “I will check my blood glucose only when I feel dizzy.”
B) “I can stop my metformin once my blood sugar is normal.”
C) “I should rotate my insulin injection sites within the same anatomical
, area.”
D) “I will avoid all carbohydrates to keep my blood sugar under control.”
Correct Answer: C) “I should rotate my insulin injection sites within the
same anatomical area.”
Rationale: Site rotation within the same area promotes consistent absorption
and prevents lipohypertrophy. Checking glucose only when symptomatic is
unsafe, stopping metformin without a provider’s order can cause
hyperglycemia, and avoiding all carbohydrates is not recommended—
consistent carbohydrate intake is key.
Question 5
A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate via continuous IV infusion. Which of the following
findings indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Urinary output 40 mL/hr
C) Respiratory rate 10/min
D) Blood pressure 138/88 mmHg
Correct Answer: C) Respiratory rate 10/min
Rationale: Magnesium toxicity causes CNS depression, leading to respiratory
depression (less than 12/min), loss of deep tendon reflexes, and oliguria. A
respiratory rate of 10/min is a critical sign requiring immediate
discontinuation of the infusion and administration of calcium gluconate. The
other findings are within safe limits.