,Q1 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A client with type 2 diabetes is prescribed metformin 500 mg PO twice daily. The
client also takes furosemide 40 mg daily. Which laboratory value indicates a
potential adverse effect requiring immediate intervention?
A. Serum creatinine 1.2 mg/dL
B. Lactic acid 4.5 mmol/L CORRECT
C. Potassium 3.8 mEq/L
D. Hemoglobin A1c 7.2%
RATIONALE: Metformin can cause lactic acidosis, especially in clients with renal impairment
(furosemide may cause dehydration). Lactic acid >4 mmol/L is concerning. Elevated creatinine,
mild hypokalemia, and slightly elevated A1c are not immediate emergencies.
Q2 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A client with a new colostomy is being discharged. Which statement indicates the
client understands self-care?
A. I will change the pouch every day and scrub the skin with soap.
B. I will measure my fluid intake and output daily.
C. I will avoid foods like broccoli and beans to reduce gas.
D. I will expect the stoma to shrink over the next few weeks. CORRECT
RATIONALE: The stoma typically shrinks over 6-8 weeks, requiring a smaller appliance. Pouch
changes should be every 3-5 days and skin should be cleansed with water. Fluid monitoring is
not specific to colostomy. Gas-forming foods may be avoided but this is not the best indicator of
overall self-care.
Page 2
,Q3 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A nurse is reviewing the laboratory results of a client who is 24 hours
post-operative following a thyroidectomy. Which finding requires immediate
action?
A. Calcium 8.9 mg/dL CORRECT
B. Thyroid stimulating hormone 2.0 mIU/L
C. White blood cell count 9,000/mm3
D. Hemoglobin 12.5 g/dL
RATIONALE: Post-thyroidectomy, hypocalcemia can occur due to parathyroid damage. Calcium
<9.0 mg/dL is low and may cause tetany. TSH is normal, WBC and hemoglobin are within normal
limits.
Q4 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A nurse is providing teaching to a client with a new prescription for warfarin.
Which instruction should the nurse include?
A. Avoid foods high in vitamin K, such as leafy greens.
B. Take aspirin for headaches instead of acetaminophen.
C. Keep your intake of vitamin K consistent from day to day. CORRECT
D. Expect to have your INR checked once every month.
RATIONALE: Consistent vitamin K intake is key to maintaining stable INR. Avoiding vitamin K is
not necessary. Aspirin increases bleeding risk. INR is checked frequently, often weekly initially.
Page 3
, Q5 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A client with a history of heart failure is receiving furosemide 40 mg IV push.
Which assessment finding indicates the need for immediate intervention?
A. Urine output 120 mL over the last 2 hours
B. Blood pressure 90/60 mm Hg CORRECT
C. Serum potassium 3.6 mEq/L
D. Weight loss of 1 kg since yesterday
RATIONALE: Hypotension can indicate excessive diuresis or hypovolemia. Urine output is
adequate. Potassium is low-normal but not critical. Weight loss is expected with diuresis.
Q6 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A nurse is assessing a client who is receiving a blood transfusion. Which finding
indicates a hemolytic reaction?
A. Urticaria and pruritus
B. Fever and low back pain CORRECT
C. Wheezing and dyspnea
D. Hypotension and tachycardia
RATIONALE: Hemolytic reactions present with fever, chills, low back pain, and hemoglobinuria.
Urticaria indicates allergic reaction. Wheezing suggests anaphylaxis. Hypotension and
tachycardia are late signs of any severe reaction.
Page 4
LIFESPAN
A client with type 2 diabetes is prescribed metformin 500 mg PO twice daily. The
client also takes furosemide 40 mg daily. Which laboratory value indicates a
potential adverse effect requiring immediate intervention?
A. Serum creatinine 1.2 mg/dL
B. Lactic acid 4.5 mmol/L CORRECT
C. Potassium 3.8 mEq/L
D. Hemoglobin A1c 7.2%
RATIONALE: Metformin can cause lactic acidosis, especially in clients with renal impairment
(furosemide may cause dehydration). Lactic acid >4 mmol/L is concerning. Elevated creatinine,
mild hypokalemia, and slightly elevated A1c are not immediate emergencies.
Q2 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A client with a new colostomy is being discharged. Which statement indicates the
client understands self-care?
A. I will change the pouch every day and scrub the skin with soap.
B. I will measure my fluid intake and output daily.
C. I will avoid foods like broccoli and beans to reduce gas.
D. I will expect the stoma to shrink over the next few weeks. CORRECT
RATIONALE: The stoma typically shrinks over 6-8 weeks, requiring a smaller appliance. Pouch
changes should be every 3-5 days and skin should be cleansed with water. Fluid monitoring is
not specific to colostomy. Gas-forming foods may be avoided but this is not the best indicator of
overall self-care.
Page 2
,Q3 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A nurse is reviewing the laboratory results of a client who is 24 hours
post-operative following a thyroidectomy. Which finding requires immediate
action?
A. Calcium 8.9 mg/dL CORRECT
B. Thyroid stimulating hormone 2.0 mIU/L
C. White blood cell count 9,000/mm3
D. Hemoglobin 12.5 g/dL
RATIONALE: Post-thyroidectomy, hypocalcemia can occur due to parathyroid damage. Calcium
<9.0 mg/dL is low and may cause tetany. TSH is normal, WBC and hemoglobin are within normal
limits.
Q4 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A nurse is providing teaching to a client with a new prescription for warfarin.
Which instruction should the nurse include?
A. Avoid foods high in vitamin K, such as leafy greens.
B. Take aspirin for headaches instead of acetaminophen.
C. Keep your intake of vitamin K consistent from day to day. CORRECT
D. Expect to have your INR checked once every month.
RATIONALE: Consistent vitamin K intake is key to maintaining stable INR. Avoiding vitamin K is
not necessary. Aspirin increases bleeding risk. INR is checked frequently, often weekly initially.
Page 3
, Q5 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A client with a history of heart failure is receiving furosemide 40 mg IV push.
Which assessment finding indicates the need for immediate intervention?
A. Urine output 120 mL over the last 2 hours
B. Blood pressure 90/60 mm Hg CORRECT
C. Serum potassium 3.6 mEq/L
D. Weight loss of 1 kg since yesterday
RATIONALE: Hypotension can indicate excessive diuresis or hypovolemia. Urine output is
adequate. Potassium is low-normal but not critical. Weight loss is expected with diuresis.
Q6 APPLY THE NURSING PROCESS TO PRIORITIZE CARE FOR CLIENTS ACROSS THE
LIFESPAN
A nurse is assessing a client who is receiving a blood transfusion. Which finding
indicates a hemolytic reaction?
A. Urticaria and pruritus
B. Fever and low back pain CORRECT
C. Wheezing and dyspnea
D. Hypotension and tachycardia
RATIONALE: Hemolytic reactions present with fever, chills, low back pain, and hemoglobinuria.
Urticaria indicates allergic reaction. Wheezing suggests anaphylaxis. Hypotension and
tachycardia are late signs of any severe reaction.
Page 4
