1. A nurse is caring for a patient with chronic renal failure. Which of
the following lab results would indicate that the patient is
experiencing a worsening of the condition?
A) Decreased serum creatinine
B) Increased hemoglobin levels
C) Increased serum potassium
D) Decreased blood urea nitrogen (BUN) levels
Answer: C) Increased serum potassium
Rationale: Chronic renal failure leads to decreased kidney function,
impairing the ability to excrete potassium. This can result in
hyperkalemia, which is a serious complication that requires immediate
attention.
2. A nurse is caring for a patient who has just been admitted for an
acute exacerbation of asthma. The nurse notes the patient is using
accessory muscles to breathe and has an oxygen saturation of 89%.
Which of the following interventions is the priority?
A) Administer a bronchodilator
B) Increase the oxygen flow rate
C) Encourage deep breathing exercises
D) Perform a chest X-ray
Answer: B) Increase the oxygen flow rate
Rationale: The priority intervention is to ensure the patient has
adequate oxygenation. An oxygen saturation of 89% is below the
normal range (95%-100%), and the use of accessory muscles indicates
respiratory distress, requiring immediate oxygen therapy to improve
oxygen levels.
,3. A nurse is teaching a patient with Type 2 diabetes how to manage
their blood glucose. Which of the following statements by the patient
indicates a need for further teaching?
A) "I should monitor my blood glucose before meals and at bedtime."
B) "I can eat my favorite foods as long as I take my insulin before
meals."
C) "I need to exercise regularly to help manage my blood sugar levels."
D) "I should avoid eating sugary foods and drinks."
Answer: B) "I can eat my favorite foods as long as I take my insulin
before meals."
Rationale: While insulin can help control blood glucose levels, it is
essential for the patient to manage their diet and exercise to prevent
blood sugar spikes. Relying on insulin alone while consuming unhealthy
foods is not an effective long-term management strategy.
4. A nurse is caring for a patient who has just undergone a knee
replacement. The patient reports severe pain despite receiving
prescribed pain medication. Which of the following actions should the
nurse take first?
A) Increase the dose of the pain medication
B) Assess the patient's surgical site for complications
C) Call the healthcare provider to report the pain
D) Offer the patient a warm compress to relieve pain
Answer: B) Assess the patient's surgical site for complications
Rationale: The first priority is to assess the surgical site to ensure there
are no complications, such as infection or bleeding, that could be
, contributing to the pain. If no complications are found, further actions
can be taken to manage the pain.
5. A nurse is caring for a patient with a history of myocardial
infarction. Which of the following is the most important intervention
to prevent further cardiac events?
A) Encourage the patient to reduce physical activity
B) Administer prescribed aspirin daily
C) Increase the patient's sodium intake to prevent dehydration
D) Encourage the patient to consume a high-fat diet
Answer: B) Administer prescribed aspirin daily
Rationale: Aspirin is commonly prescribed to reduce the risk of further
blood clots, which can prevent future myocardial infarctions. It works as
an antiplatelet agent, reducing the likelihood of clot formation.
6. A nurse is providing care to a pregnant woman who is at 32 weeks
of gestation. The patient reports feeling faint and dizzy. The nurse
notes the patient’s blood pressure is 90/60 mmHg. Which of the
following actions should the nurse take?
A) Position the patient in a left lateral position
B) Have the patient lie flat on her back
C) Increase the patient's fluid intake
D) Administer a dose of antihypertensive medication
Answer: A) Position the patient in a left lateral position
Rationale: During pregnancy, hypotension can result from uterine
compression of the vena cava, especially in the supine position. The left
the following lab results would indicate that the patient is
experiencing a worsening of the condition?
A) Decreased serum creatinine
B) Increased hemoglobin levels
C) Increased serum potassium
D) Decreased blood urea nitrogen (BUN) levels
Answer: C) Increased serum potassium
Rationale: Chronic renal failure leads to decreased kidney function,
impairing the ability to excrete potassium. This can result in
hyperkalemia, which is a serious complication that requires immediate
attention.
2. A nurse is caring for a patient who has just been admitted for an
acute exacerbation of asthma. The nurse notes the patient is using
accessory muscles to breathe and has an oxygen saturation of 89%.
Which of the following interventions is the priority?
A) Administer a bronchodilator
B) Increase the oxygen flow rate
C) Encourage deep breathing exercises
D) Perform a chest X-ray
Answer: B) Increase the oxygen flow rate
Rationale: The priority intervention is to ensure the patient has
adequate oxygenation. An oxygen saturation of 89% is below the
normal range (95%-100%), and the use of accessory muscles indicates
respiratory distress, requiring immediate oxygen therapy to improve
oxygen levels.
,3. A nurse is teaching a patient with Type 2 diabetes how to manage
their blood glucose. Which of the following statements by the patient
indicates a need for further teaching?
A) "I should monitor my blood glucose before meals and at bedtime."
B) "I can eat my favorite foods as long as I take my insulin before
meals."
C) "I need to exercise regularly to help manage my blood sugar levels."
D) "I should avoid eating sugary foods and drinks."
Answer: B) "I can eat my favorite foods as long as I take my insulin
before meals."
Rationale: While insulin can help control blood glucose levels, it is
essential for the patient to manage their diet and exercise to prevent
blood sugar spikes. Relying on insulin alone while consuming unhealthy
foods is not an effective long-term management strategy.
4. A nurse is caring for a patient who has just undergone a knee
replacement. The patient reports severe pain despite receiving
prescribed pain medication. Which of the following actions should the
nurse take first?
A) Increase the dose of the pain medication
B) Assess the patient's surgical site for complications
C) Call the healthcare provider to report the pain
D) Offer the patient a warm compress to relieve pain
Answer: B) Assess the patient's surgical site for complications
Rationale: The first priority is to assess the surgical site to ensure there
are no complications, such as infection or bleeding, that could be
, contributing to the pain. If no complications are found, further actions
can be taken to manage the pain.
5. A nurse is caring for a patient with a history of myocardial
infarction. Which of the following is the most important intervention
to prevent further cardiac events?
A) Encourage the patient to reduce physical activity
B) Administer prescribed aspirin daily
C) Increase the patient's sodium intake to prevent dehydration
D) Encourage the patient to consume a high-fat diet
Answer: B) Administer prescribed aspirin daily
Rationale: Aspirin is commonly prescribed to reduce the risk of further
blood clots, which can prevent future myocardial infarctions. It works as
an antiplatelet agent, reducing the likelihood of clot formation.
6. A nurse is providing care to a pregnant woman who is at 32 weeks
of gestation. The patient reports feeling faint and dizzy. The nurse
notes the patient’s blood pressure is 90/60 mmHg. Which of the
following actions should the nurse take?
A) Position the patient in a left lateral position
B) Have the patient lie flat on her back
C) Increase the patient's fluid intake
D) Administer a dose of antihypertensive medication
Answer: A) Position the patient in a left lateral position
Rationale: During pregnancy, hypotension can result from uterine
compression of the vena cava, especially in the supine position. The left
