Package- 4 Versions QUESTIONS WITH ANSWERS
1. A nurse is caring for a client with pneumonia who suddenly becomes confused and restless.
Which action should the nurse take first?
A. Administer the prescribed antibiotic
B. Check the client's oxygen saturation
C. Encourage oral fluids
D. Obtain a urine specimen
Answer:. B
Rationale: Acute confusion and restlessness can indicate hypoxemia. Airway and breathing are
priority.
2. A client with heart failure reports a 2.3-kg (5-lb) weight gain over 3 days. What should the
nurse do?
A. Encourage increased fluid intake
B. Notify the provider
C. Reassure the client this is expected
D. Encourage a high-sodium diet
Answer:. B
Rationale: Rapid weight gain indicates fluid retention and worsening heart failure.
,3. Which finding should the nurse recognize as a manifestation of hypoglycemia?
A. Polyuria
B. Warm, dry skin
C. Diaphoresis and tremors
D. Fruity breath
Answer:. C
Rationale: Hypoglycemia activates the sympathetic nervous system, causing sweating, tremors,
tachycardia, and anxiety.
4. A conscious client with diabetes has a blood glucose level of 48 mg/dL. Which intervention is
appropriate?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Restrict oral intake
D. Administer long-acting insulin
Answer:. B
Rationale: A conscious client who can safely swallow should receive approximately 15 g of fast-
acting carbohydrate.
, 5. A client receiving morphine has a respiratory rate of 7/min. Which medication should the
nurse anticipate?
A. Flumazenil
B. Naloxone
C. Protamine
D. Vitamin K
Answer:. B
Rationale: Naloxone reverses opioid-induced respiratory depression.
6. A client taking warfarin has an INR of 6.2. Which action is appropriate?
A. Administer the scheduled dose
B. Hold the medication and notify the provider
C. Administer aspirin
D. Encourage vigorous exercise
Answer:. B
Rationale: An INR this high significantly increases bleeding risk.
7. Which finding in a client receiving digoxin should the nurse report?
A. Heart rate of 88/min