. A nurse is assessing a 60-year-old client with hypertension. Which of
the following findings should the nurse report immediately?
A) Blood pressure of 140/88 mm Hg
B) Complaints of mild headaches
C) Blood pressure of 200/110 mm Hg
D) Occasional dizziness when standing up
Answer: C) Blood pressure of 200/110 mm Hg
Rationale:
A blood pressure of 200/110 mm Hg is considered a hypertensive crisis
and requires immediate intervention. It can lead to complications such
as stroke or organ damage, and the nurse must report it to the
healthcare provider immediately.
2. A 30-year-old woman diagnosed with a new pregnancy presents
with morning nausea and vomiting. Which of the following should the
nurse recommend?
A) Limit fluid intake to prevent vomiting
B) Take prenatal vitamins on an empty stomach
C) Eat small, frequent meals throughout the day
D) Avoid consuming carbohydrates until nausea resolves
Answer: C) Eat small, frequent meals throughout the day
Rationale:
Morning nausea and vomiting are common during early pregnancy
(morning sickness). Eating small, frequent meals can help maintain
blood sugar levels and reduce nausea. It is also important to stay
hydrated and avoid large meals, which can exacerbate symptoms.
,3. Which of the following interventions should the nurse implement
for a client with a history of congestive heart failure who is
experiencing shortness of breath?
A) Encourage deep breathing exercises
B) Place the client in a supine position to promote lung expansion
C) Administer oxygen as prescribed
D) Withhold all medications until further assessment
Answer: C) Administer oxygen as prescribed
Rationale:
In a client with congestive heart failure, shortness of breath is often
related to fluid buildup in the lungs. Administering oxygen helps
improve oxygenation and relieve respiratory distress. Elevating the head
of the bed (not supine) and assessing fluid status are also important
steps, but oxygen therapy is a priority in this scenario.
4. A nurse is preparing a client for a colonoscopy. Which of the
following instructions is most important to include in pre-procedure
teaching?
A) "You may eat a light meal 12 hours before the procedure."
B) "You will need to drink a bowel prep solution the evening before the
procedure."
C) "The procedure will be done under general anesthesia."
D) "You will need to stay on a clear liquid diet for 1 day prior to the
procedure."
Answer: B) "You will need to drink a bowel prep solution the evening
before the procedure."
,Rationale:
A bowel prep solution is typically prescribed to clean out the colon
before a colonoscopy to ensure clear visualization of the colon lining.
Patients are usually required to follow a clear liquid diet the day before
the procedure, but drinking the prep solution is crucial for an effective
procedure.
5. A nurse is providing care for a client who has recently undergone a
total hip replacement. Which action should the nurse prioritize to
prevent dislocation of the hip?
A) Turn the client every 2 hours
B) Keep the affected leg in a neutral position
C) Encourage early ambulation
D) Place a pillow between the client's legs when turning
Answer: B) Keep the affected leg in a neutral position
Rationale:
After a hip replacement, keeping the affected leg in a neutral position
(avoiding internal or external rotation) is crucial to prevent dislocation
of the new hip joint. It is also essential to avoid excessive flexion and
adduction of the hip.
6. A nurse is caring for a client with diabetes mellitus who is
experiencing hypoglycemia. Which of the following is the most
appropriate first action?
A) Administer 10 units of regular insulin
B) Offer the client a glass of fruit juice
, C) Encourage the client to drink water
D) Reassess the client's blood glucose in 30 minutes
Answer: B) Offer the client a glass of fruit juice
Rationale:
In hypoglycemia, immediate action is needed to raise blood sugar
levels. Offering a quick source of glucose, such as fruit juice, is
recommended. If the client is conscious and able to swallow, this is the
fastest way to restore glucose levels. Once blood sugar is stabilized,
further actions can be taken.
7. A nurse is teaching a client with asthma about the use of a metered-
dose inhaler (MDI). Which statement by the client indicates a need for
further teaching?
A) "I will shake the inhaler before each use."
B) "I will exhale before using the inhaler."
C) "I will hold my breath for 10 seconds after using the inhaler."
D) "I will clean the inhaler with warm water once a week."
Answer: D) "I will clean the inhaler with warm water once a week."
Rationale:
MDIs should be cleaned regularly, but cleaning them with warm water
every week is not a standard recommendation. The inhaler should be
cleaned according to the manufacturer's instructions, typically by
removing the canister and cleaning the mouthpiece with a dry cloth or
in warm water. Over-washing can potentially cause issues with the
inhaler mechanism.
the following findings should the nurse report immediately?
A) Blood pressure of 140/88 mm Hg
B) Complaints of mild headaches
C) Blood pressure of 200/110 mm Hg
D) Occasional dizziness when standing up
Answer: C) Blood pressure of 200/110 mm Hg
Rationale:
A blood pressure of 200/110 mm Hg is considered a hypertensive crisis
and requires immediate intervention. It can lead to complications such
as stroke or organ damage, and the nurse must report it to the
healthcare provider immediately.
2. A 30-year-old woman diagnosed with a new pregnancy presents
with morning nausea and vomiting. Which of the following should the
nurse recommend?
A) Limit fluid intake to prevent vomiting
B) Take prenatal vitamins on an empty stomach
C) Eat small, frequent meals throughout the day
D) Avoid consuming carbohydrates until nausea resolves
Answer: C) Eat small, frequent meals throughout the day
Rationale:
Morning nausea and vomiting are common during early pregnancy
(morning sickness). Eating small, frequent meals can help maintain
blood sugar levels and reduce nausea. It is also important to stay
hydrated and avoid large meals, which can exacerbate symptoms.
,3. Which of the following interventions should the nurse implement
for a client with a history of congestive heart failure who is
experiencing shortness of breath?
A) Encourage deep breathing exercises
B) Place the client in a supine position to promote lung expansion
C) Administer oxygen as prescribed
D) Withhold all medications until further assessment
Answer: C) Administer oxygen as prescribed
Rationale:
In a client with congestive heart failure, shortness of breath is often
related to fluid buildup in the lungs. Administering oxygen helps
improve oxygenation and relieve respiratory distress. Elevating the head
of the bed (not supine) and assessing fluid status are also important
steps, but oxygen therapy is a priority in this scenario.
4. A nurse is preparing a client for a colonoscopy. Which of the
following instructions is most important to include in pre-procedure
teaching?
A) "You may eat a light meal 12 hours before the procedure."
B) "You will need to drink a bowel prep solution the evening before the
procedure."
C) "The procedure will be done under general anesthesia."
D) "You will need to stay on a clear liquid diet for 1 day prior to the
procedure."
Answer: B) "You will need to drink a bowel prep solution the evening
before the procedure."
,Rationale:
A bowel prep solution is typically prescribed to clean out the colon
before a colonoscopy to ensure clear visualization of the colon lining.
Patients are usually required to follow a clear liquid diet the day before
the procedure, but drinking the prep solution is crucial for an effective
procedure.
5. A nurse is providing care for a client who has recently undergone a
total hip replacement. Which action should the nurse prioritize to
prevent dislocation of the hip?
A) Turn the client every 2 hours
B) Keep the affected leg in a neutral position
C) Encourage early ambulation
D) Place a pillow between the client's legs when turning
Answer: B) Keep the affected leg in a neutral position
Rationale:
After a hip replacement, keeping the affected leg in a neutral position
(avoiding internal or external rotation) is crucial to prevent dislocation
of the new hip joint. It is also essential to avoid excessive flexion and
adduction of the hip.
6. A nurse is caring for a client with diabetes mellitus who is
experiencing hypoglycemia. Which of the following is the most
appropriate first action?
A) Administer 10 units of regular insulin
B) Offer the client a glass of fruit juice
, C) Encourage the client to drink water
D) Reassess the client's blood glucose in 30 minutes
Answer: B) Offer the client a glass of fruit juice
Rationale:
In hypoglycemia, immediate action is needed to raise blood sugar
levels. Offering a quick source of glucose, such as fruit juice, is
recommended. If the client is conscious and able to swallow, this is the
fastest way to restore glucose levels. Once blood sugar is stabilized,
further actions can be taken.
7. A nurse is teaching a client with asthma about the use of a metered-
dose inhaler (MDI). Which statement by the client indicates a need for
further teaching?
A) "I will shake the inhaler before each use."
B) "I will exhale before using the inhaler."
C) "I will hold my breath for 10 seconds after using the inhaler."
D) "I will clean the inhaler with warm water once a week."
Answer: D) "I will clean the inhaler with warm water once a week."
Rationale:
MDIs should be cleaned regularly, but cleaning them with warm water
every week is not a standard recommendation. The inhaler should be
cleaned according to the manufacturer's instructions, typically by
removing the canister and cleaning the mouthpiece with a dry cloth or
in warm water. Over-washing can potentially cause issues with the
inhaler mechanism.
