1. A nurse is caring for a client who has a spinal cord injury at T4 and reports a sudden, severe
headache. The client’s blood pressure is 188/96 mmHg. Which of the following actions should
the nurse take first?
A. Check the client’s urinary catheter for kinks.
B. Administer an antihypertensive medication.
C. Place the client in a high-Fowler’s position.
D. Assess the client for fecal impaction.
Answer: C
Rationale: The client is experiencing autonomic dysreflexia. The priority action is to sit the
client upright to use orthostatic pressure to lower the blood pressure before addressing the
stimulus.
2. A nurse is providing teaching to a client who has a new prescription for ethambutol to treat
tuberculosis. Which of the following adverse effects should the nurse instruct the client to
report?
A. Tinnitus
B. Orange discoloration of urine
C. Persistent metallic taste
,D. Changes in visual acuity
Answer: D
Rationale: Ethambutol can cause optic neuritis, which affects visual acuity and color
discrimination. Clients must have periodic vision screenings.
3. A nurse is reviewing the laboratory results of a client who has a potassium level of 2.8
mEq/L. Which of the following ECG findings should the nurse expect?
A. Tall, peaked T waves
B. Presence of U waves
C. Widened QRS complex
D. ST-segment elevation
Answer: B
Rationale: Hypokalemia (potassium < 3.5 mEq/L) typically manifests as flat or inverted T
waves and the appearance of U waves on an ECG.
4. A nurse is assessing a client who is at 34 weeks of gestation and has preeclampsia. Which
of the following findings is the most concerning?
A. 1+ pitting edema in the lower extremities
B. Weight gain of 1 lb in one week
C. Blood pressure of 142/92 mmHg
D. 4+ proteinuria on a dipstick
, Answer: D
Rationale: Severe proteinuria (3+ or 4+) is a classic sign of worsening preeclampsia and
indicates significant glomerular damage.
5. A nurse is preparing to care for a client who has been placed on neutropenic precautions.
Which of the following interventions should the nurse include?
A. Encourage the client to eat fresh fruits and vegetables.
B. Place a box of humidified oxygen in the room.
C. Prohibit fresh flowers and potted plants in the room.
D. Wear an N95 respirator mask when entering the room.
Answer: C
Rationale: Neutropenic precautions aim to prevent infection. Fresh flowers and plants can
harbor mold and bacteria that pose a risk to immunocompromised clients.
6. A nurse is teaching the parent of a child who has cystic fibrosis about the administration of
pancreatic enzymes. When should the nurse instruct the parent to give the enzymes?
A. With every meal and snack
B. Once daily in the morning
C. Two hours after meals
D. Only when the child has a fatty meal
Answer: A