1. Which of the following actions is the nurse's priority when caring
for a client with a newly placed urinary catheter?
A) Monitor urine output every hour
B) Perform catheter care every 12 hours
C) Educate the client about preventing infection
D) Ensure the catheter is secured properly
Answer: D) Ensure the catheter is secured properly
Rationale: The priority action is to ensure the catheter is properly
secured to prevent movement, which could cause irritation, injury, or
accidental removal. Monitoring urine output, educating the client, and
performing catheter care are also important but follow securing the
catheter.
2. A client is receiving an IV infusion of normal saline. The nurse notes
the client's arm is swollen, pale, and cool to the touch. What should
the nurse do first?
A) Continue the IV infusion at a slower rate
B) Stop the infusion and remove the catheter
C) Increase the rate of the IV infusion
D) Apply a warm compress to the area
Answer: B) Stop the infusion and remove the catheter
Rationale: Swelling, pallor, and coolness at the IV site indicate
infiltration, where the IV solution is leaking into the surrounding tissue.
The first step is to stop the infusion and remove the catheter to prevent
further tissue damage.
,3. A nurse is caring for a client with pneumonia who has a SpO2 of
88%. What is the priority nursing action?
A) Administer oxygen as prescribed
B) Call the healthcare provider
C) Encourage coughing and deep breathing
D) Obtain a chest x-ray
Answer: A) Administer oxygen as prescribed
Rationale: A SpO2 of 88% indicates hypoxemia. The nurse should
prioritize administering oxygen to improve oxygen saturation. Other
actions, like calling the healthcare provider, coughing, and deep
breathing, may follow depending on the situation.
4. A client who is receiving a blood transfusion begins to report chills
and back pain. What is the nurse's first priority?
A) Notify the healthcare provider
B) Administer an antipyretic medication
C) Stop the transfusion and maintain IV access with saline
D) Take the client’s vital signs
Answer: C) Stop the transfusion and maintain IV access with saline
Rationale: Chills and back pain can indicate a transfusion reaction. The
nurse should immediately stop the transfusion, maintain IV access with
normal saline, and notify the healthcare provider for further
instructions.
5. Which of the following is an appropriate intervention when caring
for a client who is at risk for falling?
, A) Encourage the client to walk independently without assistance
B) Keep the call light out of the client’s reach to encourage
independence
C) Ensure the client’s room is well-lit and free from obstacles
D) Place all personal items on a high shelf
Answer: C) Ensure the client’s room is well-lit and free from obstacles
Rationale: Preventing falls involves making the environment safe.
Ensuring proper lighting and removing obstacles are key components.
Keeping personal items within reach and providing assistance when
necessary are important to ensure client safety.
6. A nurse is providing discharge instructions to a client who had a hip
replacement. Which instruction should the nurse include?
A) "Do not cross your legs for at least 8 weeks."
B) "You can drive 1 week after surgery."
C) "Avoid weight-bearing on the affected leg for 48 hours."
D) "You should avoid using a walker to promote independence."
Answer: A) "Do not cross your legs for at least 8 weeks."
Rationale: After hip replacement surgery, crossing the legs can increase
the risk of dislocation. The nurse should reinforce avoiding this activity
to ensure proper healing. Driving and bearing weight should be avoided
until cleared by the healthcare provider, and using a walker is
encouraged for safety.
7. A nurse is assessing a 5-year-old child post-tonsillectomy. Which
finding requires immediate intervention?
for a client with a newly placed urinary catheter?
A) Monitor urine output every hour
B) Perform catheter care every 12 hours
C) Educate the client about preventing infection
D) Ensure the catheter is secured properly
Answer: D) Ensure the catheter is secured properly
Rationale: The priority action is to ensure the catheter is properly
secured to prevent movement, which could cause irritation, injury, or
accidental removal. Monitoring urine output, educating the client, and
performing catheter care are also important but follow securing the
catheter.
2. A client is receiving an IV infusion of normal saline. The nurse notes
the client's arm is swollen, pale, and cool to the touch. What should
the nurse do first?
A) Continue the IV infusion at a slower rate
B) Stop the infusion and remove the catheter
C) Increase the rate of the IV infusion
D) Apply a warm compress to the area
Answer: B) Stop the infusion and remove the catheter
Rationale: Swelling, pallor, and coolness at the IV site indicate
infiltration, where the IV solution is leaking into the surrounding tissue.
The first step is to stop the infusion and remove the catheter to prevent
further tissue damage.
,3. A nurse is caring for a client with pneumonia who has a SpO2 of
88%. What is the priority nursing action?
A) Administer oxygen as prescribed
B) Call the healthcare provider
C) Encourage coughing and deep breathing
D) Obtain a chest x-ray
Answer: A) Administer oxygen as prescribed
Rationale: A SpO2 of 88% indicates hypoxemia. The nurse should
prioritize administering oxygen to improve oxygen saturation. Other
actions, like calling the healthcare provider, coughing, and deep
breathing, may follow depending on the situation.
4. A client who is receiving a blood transfusion begins to report chills
and back pain. What is the nurse's first priority?
A) Notify the healthcare provider
B) Administer an antipyretic medication
C) Stop the transfusion and maintain IV access with saline
D) Take the client’s vital signs
Answer: C) Stop the transfusion and maintain IV access with saline
Rationale: Chills and back pain can indicate a transfusion reaction. The
nurse should immediately stop the transfusion, maintain IV access with
normal saline, and notify the healthcare provider for further
instructions.
5. Which of the following is an appropriate intervention when caring
for a client who is at risk for falling?
, A) Encourage the client to walk independently without assistance
B) Keep the call light out of the client’s reach to encourage
independence
C) Ensure the client’s room is well-lit and free from obstacles
D) Place all personal items on a high shelf
Answer: C) Ensure the client’s room is well-lit and free from obstacles
Rationale: Preventing falls involves making the environment safe.
Ensuring proper lighting and removing obstacles are key components.
Keeping personal items within reach and providing assistance when
necessary are important to ensure client safety.
6. A nurse is providing discharge instructions to a client who had a hip
replacement. Which instruction should the nurse include?
A) "Do not cross your legs for at least 8 weeks."
B) "You can drive 1 week after surgery."
C) "Avoid weight-bearing on the affected leg for 48 hours."
D) "You should avoid using a walker to promote independence."
Answer: A) "Do not cross your legs for at least 8 weeks."
Rationale: After hip replacement surgery, crossing the legs can increase
the risk of dislocation. The nurse should reinforce avoiding this activity
to ensure proper healing. Driving and bearing weight should be avoided
until cleared by the healthcare provider, and using a walker is
encouraged for safety.
7. A nurse is assessing a 5-year-old child post-tonsillectomy. Which
finding requires immediate intervention?
