1. A 70-year-old client with chronic heart failure is being discharged
from the hospital. Which of the following instructions should the
nurse include in the discharge teaching?
A) "You should increase your daily fluid intake to 3 liters."
B) "Avoid taking your prescribed diuretic if you experience dizziness."
C) "Monitor your weight daily and report a gain of 2 pounds or more in
a day."
D) "It is safe to take nonprescription cold medications without checking
with your healthcare provider."
Answer: C) "Monitor your weight daily and report a gain of 2 pounds or
more in a day."
Rationale: Weight gain of 2 pounds or more in a day can be an
indication of fluid retention, which is common in heart failure. Clients
should be taught to monitor their weight daily to assess for changes
that could signal worsening heart failure. Option A is incorrect because
fluid restriction is typically advised in heart failure. Option B is incorrect
because diuretics should not be skipped, and dizziness should be
reported to the healthcare provider for further evaluation. Option D is
incorrect because many over-the-counter medications, especially those
containing decongestants, can worsen heart failure.
2. A nurse is caring for a client post-appendectomy. The client
suddenly reports severe, localized abdominal pain, accompanied by a
rigid abdomen and a high fever. Which of the following is the nurse's
priority action?
A) Notify the healthcare provider.
B) Administer the prescribed pain medication.
,C) Assess the client's vital signs.
D) Prepare the client for an emergency surgery.
Answer: A) Notify the healthcare provider.
Rationale: The symptoms described (severe abdominal pain, rigid
abdomen, high fever) indicate possible peritonitis, a surgical emergency.
The priority is to notify the healthcare provider immediately for further
assessment and intervention. While assessing vital signs (option C) and
preparing for surgery (option D) are important, notifying the provider is
the first step in managing a potential complication such as peritonitis.
3. A nurse is caring for a 5-year-old child with a diagnosis of asthma.
Which of the following is the most appropriate action to teach the
child and parents to prevent asthma exacerbations?
A) "Make sure your child avoids all outdoor activities to prevent
exposure to allergens."
B) "Ensure your child uses the inhaler only during asthma attacks."
C) "Encourage your child to take daily medication as prescribed, even if
they feel fine."
D) "Only administer the inhaler when the child is experiencing difficulty
breathing."
Answer: C) "Encourage your child to take daily medication as
prescribed, even if they feel fine."
Rationale: Asthma medications, particularly controllers like inhaled
corticosteroids, need to be taken daily to reduce inflammation in the
airways and prevent exacerbations. Option A is incorrect because some
outdoor activities may be safe if allergens are controlled or avoided.
Option B and D are incorrect because reliever medications (such as
,albuterol) are used for acute symptoms, but long-term control
medications need to be taken regularly.
4. A nurse is caring for a client who is 24 hours post-op after a total hip
replacement. Which of the following actions is a priority for
preventing post-operative complications?
A) Encouraging the client to perform deep breathing and coughing
exercises.
B) Assisting the client to change position every 2 hours.
C) Monitoring the client's incision for signs of infection.
D) Administering prescribed anticoagulant therapy as ordered.
Answer: D) Administering prescribed anticoagulant therapy as ordered.
Rationale: The primary concern after hip replacement surgery is the
prevention of deep vein thrombosis (DVT) and pulmonary embolism
(PE). Administering anticoagulants as prescribed is essential for
preventing these complications. Option A is important for respiratory
function, but preventing thromboembolism is the priority. Option B is
necessary for preventing pressure ulcers, and Option C is necessary for
infection control, but neither are as urgent as preventing
thromboembolic events.
5. A nurse is caring for a 40-year-old client with type 1 diabetes
mellitus. The client reports feeling weak and shaky. Which of the
following is the nurse's first action?
A) Administer 15 grams of a fast-acting carbohydrate.
B) Administer the prescribed insulin dose.
, C) Encourage the client to drink water.
D) Obtain a fingerstick blood glucose level.
Answer: D) Obtain a fingerstick blood glucose level.
Rationale: The nurse’s first action should be to assess the client's blood
glucose level to determine whether the symptoms are due to
hypoglycemia or another cause. Once the blood glucose is measured,
appropriate action can be taken. If the glucose level is low, 15 grams of
a fast-acting carbohydrate should be administered (option A).
Administering insulin (option B) would worsen hypoglycemia if the
client’s blood glucose is already low. Encouraging water (option C) may
not address the immediate concern of hypoglycemia.
6. A nurse is preparing to administer an intramuscular injection of
morphine sulfate to a postoperative client. Which of the following
actions is most important for the nurse to take?
A) Massage the injection site after administering the medication.
B) Inject the medication slowly to reduce the risk of tissue damage.
C) Use the ventrogluteal site for injection.
D) Withdraw the medication from the vial into a 3 mL syringe.
Answer: C) Use the ventrogluteal site for injection.
Rationale: The ventrogluteal site is the safest and most appropriate site
for administering intramuscular injections, especially for medications
like morphine, which are irritating to tissue. Option A (massaging the
site) may cause discomfort and increase the risk of tissue damage.
Option B is unnecessary, as the injection should be given at a moderate
speed to avoid discomfort but not too slowly to prevent tissue irritation.
Option D is incorrect because 1-2 mL syringes are typically sufficient for
morphine injections, and a 3 mL syringe is often larger than necessary.
from the hospital. Which of the following instructions should the
nurse include in the discharge teaching?
A) "You should increase your daily fluid intake to 3 liters."
B) "Avoid taking your prescribed diuretic if you experience dizziness."
C) "Monitor your weight daily and report a gain of 2 pounds or more in
a day."
D) "It is safe to take nonprescription cold medications without checking
with your healthcare provider."
Answer: C) "Monitor your weight daily and report a gain of 2 pounds or
more in a day."
Rationale: Weight gain of 2 pounds or more in a day can be an
indication of fluid retention, which is common in heart failure. Clients
should be taught to monitor their weight daily to assess for changes
that could signal worsening heart failure. Option A is incorrect because
fluid restriction is typically advised in heart failure. Option B is incorrect
because diuretics should not be skipped, and dizziness should be
reported to the healthcare provider for further evaluation. Option D is
incorrect because many over-the-counter medications, especially those
containing decongestants, can worsen heart failure.
2. A nurse is caring for a client post-appendectomy. The client
suddenly reports severe, localized abdominal pain, accompanied by a
rigid abdomen and a high fever. Which of the following is the nurse's
priority action?
A) Notify the healthcare provider.
B) Administer the prescribed pain medication.
,C) Assess the client's vital signs.
D) Prepare the client for an emergency surgery.
Answer: A) Notify the healthcare provider.
Rationale: The symptoms described (severe abdominal pain, rigid
abdomen, high fever) indicate possible peritonitis, a surgical emergency.
The priority is to notify the healthcare provider immediately for further
assessment and intervention. While assessing vital signs (option C) and
preparing for surgery (option D) are important, notifying the provider is
the first step in managing a potential complication such as peritonitis.
3. A nurse is caring for a 5-year-old child with a diagnosis of asthma.
Which of the following is the most appropriate action to teach the
child and parents to prevent asthma exacerbations?
A) "Make sure your child avoids all outdoor activities to prevent
exposure to allergens."
B) "Ensure your child uses the inhaler only during asthma attacks."
C) "Encourage your child to take daily medication as prescribed, even if
they feel fine."
D) "Only administer the inhaler when the child is experiencing difficulty
breathing."
Answer: C) "Encourage your child to take daily medication as
prescribed, even if they feel fine."
Rationale: Asthma medications, particularly controllers like inhaled
corticosteroids, need to be taken daily to reduce inflammation in the
airways and prevent exacerbations. Option A is incorrect because some
outdoor activities may be safe if allergens are controlled or avoided.
Option B and D are incorrect because reliever medications (such as
,albuterol) are used for acute symptoms, but long-term control
medications need to be taken regularly.
4. A nurse is caring for a client who is 24 hours post-op after a total hip
replacement. Which of the following actions is a priority for
preventing post-operative complications?
A) Encouraging the client to perform deep breathing and coughing
exercises.
B) Assisting the client to change position every 2 hours.
C) Monitoring the client's incision for signs of infection.
D) Administering prescribed anticoagulant therapy as ordered.
Answer: D) Administering prescribed anticoagulant therapy as ordered.
Rationale: The primary concern after hip replacement surgery is the
prevention of deep vein thrombosis (DVT) and pulmonary embolism
(PE). Administering anticoagulants as prescribed is essential for
preventing these complications. Option A is important for respiratory
function, but preventing thromboembolism is the priority. Option B is
necessary for preventing pressure ulcers, and Option C is necessary for
infection control, but neither are as urgent as preventing
thromboembolic events.
5. A nurse is caring for a 40-year-old client with type 1 diabetes
mellitus. The client reports feeling weak and shaky. Which of the
following is the nurse's first action?
A) Administer 15 grams of a fast-acting carbohydrate.
B) Administer the prescribed insulin dose.
, C) Encourage the client to drink water.
D) Obtain a fingerstick blood glucose level.
Answer: D) Obtain a fingerstick blood glucose level.
Rationale: The nurse’s first action should be to assess the client's blood
glucose level to determine whether the symptoms are due to
hypoglycemia or another cause. Once the blood glucose is measured,
appropriate action can be taken. If the glucose level is low, 15 grams of
a fast-acting carbohydrate should be administered (option A).
Administering insulin (option B) would worsen hypoglycemia if the
client’s blood glucose is already low. Encouraging water (option C) may
not address the immediate concern of hypoglycemia.
6. A nurse is preparing to administer an intramuscular injection of
morphine sulfate to a postoperative client. Which of the following
actions is most important for the nurse to take?
A) Massage the injection site after administering the medication.
B) Inject the medication slowly to reduce the risk of tissue damage.
C) Use the ventrogluteal site for injection.
D) Withdraw the medication from the vial into a 3 mL syringe.
Answer: C) Use the ventrogluteal site for injection.
Rationale: The ventrogluteal site is the safest and most appropriate site
for administering intramuscular injections, especially for medications
like morphine, which are irritating to tissue. Option A (massaging the
site) may cause discomfort and increase the risk of tissue damage.
Option B is unnecessary, as the injection should be given at a moderate
speed to avoid discomfort but not too slowly to prevent tissue irritation.
Option D is incorrect because 1-2 mL syringes are typically sufficient for
morphine injections, and a 3 mL syringe is often larger than necessary.
