1. A nurse is caring for a client with a chest tube. Which of the
following actions is appropriate for preventing complications?
a) Ensure the chest tube is clamped during ambulation.
b) Keep the chest tube drainage system below the level of the chest.
c) Milk the chest tube every hour to prevent clotting.
d) Remove the chest tube when the drainage is less than 10 mL per day.
Answer: b) Keep the chest tube drainage system below the level of the
chest.
Rationale: The chest tube drainage system should always be kept below
the level of the chest to promote drainage by gravity and prevent
backflow into the pleural space. Clamping the tube, milking it, or
removing it prematurely are not recommended practices and could lead
to complications.
2. A nurse is caring for a client with a history of type 1 diabetes. The
client is feeling dizzy, sweaty, and has a blood glucose level of 40
mg/dL. What is the priority intervention?
a) Administer insulin
b) Give the client a glass of water
c) Provide the client with 15-20 grams of fast-acting carbohydrate
d) Offer the client a high-protein snack
Answer: c) Provide the client with 15-20 grams of fast-acting
carbohydrate.
Rationale: The client is experiencing hypoglycemia (low blood glucose),
so the immediate intervention is to provide a source of glucose (e.g.,
juice, glucose tablets) to raise blood sugar levels. Administering insulin
or giving a high-protein snack would worsen hypoglycemia.
,3. A nurse is providing discharge teaching to a client who will be
taking warfarin (Coumadin) at home. Which of the following
statements by the client indicates an understanding of the teaching?
a) "I will avoid all green leafy vegetables in my diet."
b) "I will take my medication at the same time each day."
c) "I can take over-the-counter aspirin if I develop a headache."
d) "I should increase my intake of vitamin K to prevent bleeding."
Answer: b) "I will take my medication at the same time each day."
Rationale: Warfarin should be taken at the same time each day to
maintain consistent blood levels. Clients taking warfarin should avoid
drastic changes in vitamin K intake (not completely eliminate it), but
they don't need to avoid all green leafy vegetables. Aspirin can increase
bleeding risk, so it should be avoided unless prescribed by the
healthcare provider.
4. A nurse is caring for a client with a newly diagnosed ulcerative
colitis. Which of the following is the most appropriate dietary
modification for this client?
a) High-fat, low-fiber diet
b) Low-protein, high-carbohydrate diet
c) High-protein, low-fiber diet
d) Low-sodium, high-potassium diet
Answer: c) High-protein, low-fiber diet.
Rationale: Clients with ulcerative colitis are often advised to consume a
high-protein, low-fiber diet to reduce irritation of the gastrointestinal
, tract and support healing. A low-fiber diet helps minimize bowel
stimulation and diarrhea.
5. A nurse is assessing a client with a diagnosis of acute renal failure.
Which of the following laboratory values would the nurse expect to
find elevated?
a) Hemoglobin
b) Creatinine
c) Calcium
d) Platelets
Answer: b) Creatinine.
Rationale: In acute renal failure, the kidneys are unable to excrete
waste products, leading to an accumulation of substances such as
creatinine in the blood. Hemoglobin, calcium, and platelets are typically
not elevated in renal failure, and they would not be the primary
indicators.
6. A client is receiving a blood transfusion and begins to experience
chills, fever, and hypotension. What is the first priority nursing action?
a) Slow the transfusion rate
b) Administer acetaminophen for fever
c) Stop the transfusion immediately
d) Change the IV infusion to normal saline
Answer: c) Stop the transfusion immediately.
Rationale: The client is likely experiencing a transfusion reaction. The
first priority is to stop the transfusion immediately to prevent further
complications, followed by notifying the healthcare provider and taking
following actions is appropriate for preventing complications?
a) Ensure the chest tube is clamped during ambulation.
b) Keep the chest tube drainage system below the level of the chest.
c) Milk the chest tube every hour to prevent clotting.
d) Remove the chest tube when the drainage is less than 10 mL per day.
Answer: b) Keep the chest tube drainage system below the level of the
chest.
Rationale: The chest tube drainage system should always be kept below
the level of the chest to promote drainage by gravity and prevent
backflow into the pleural space. Clamping the tube, milking it, or
removing it prematurely are not recommended practices and could lead
to complications.
2. A nurse is caring for a client with a history of type 1 diabetes. The
client is feeling dizzy, sweaty, and has a blood glucose level of 40
mg/dL. What is the priority intervention?
a) Administer insulin
b) Give the client a glass of water
c) Provide the client with 15-20 grams of fast-acting carbohydrate
d) Offer the client a high-protein snack
Answer: c) Provide the client with 15-20 grams of fast-acting
carbohydrate.
Rationale: The client is experiencing hypoglycemia (low blood glucose),
so the immediate intervention is to provide a source of glucose (e.g.,
juice, glucose tablets) to raise blood sugar levels. Administering insulin
or giving a high-protein snack would worsen hypoglycemia.
,3. A nurse is providing discharge teaching to a client who will be
taking warfarin (Coumadin) at home. Which of the following
statements by the client indicates an understanding of the teaching?
a) "I will avoid all green leafy vegetables in my diet."
b) "I will take my medication at the same time each day."
c) "I can take over-the-counter aspirin if I develop a headache."
d) "I should increase my intake of vitamin K to prevent bleeding."
Answer: b) "I will take my medication at the same time each day."
Rationale: Warfarin should be taken at the same time each day to
maintain consistent blood levels. Clients taking warfarin should avoid
drastic changes in vitamin K intake (not completely eliminate it), but
they don't need to avoid all green leafy vegetables. Aspirin can increase
bleeding risk, so it should be avoided unless prescribed by the
healthcare provider.
4. A nurse is caring for a client with a newly diagnosed ulcerative
colitis. Which of the following is the most appropriate dietary
modification for this client?
a) High-fat, low-fiber diet
b) Low-protein, high-carbohydrate diet
c) High-protein, low-fiber diet
d) Low-sodium, high-potassium diet
Answer: c) High-protein, low-fiber diet.
Rationale: Clients with ulcerative colitis are often advised to consume a
high-protein, low-fiber diet to reduce irritation of the gastrointestinal
, tract and support healing. A low-fiber diet helps minimize bowel
stimulation and diarrhea.
5. A nurse is assessing a client with a diagnosis of acute renal failure.
Which of the following laboratory values would the nurse expect to
find elevated?
a) Hemoglobin
b) Creatinine
c) Calcium
d) Platelets
Answer: b) Creatinine.
Rationale: In acute renal failure, the kidneys are unable to excrete
waste products, leading to an accumulation of substances such as
creatinine in the blood. Hemoglobin, calcium, and platelets are typically
not elevated in renal failure, and they would not be the primary
indicators.
6. A client is receiving a blood transfusion and begins to experience
chills, fever, and hypotension. What is the first priority nursing action?
a) Slow the transfusion rate
b) Administer acetaminophen for fever
c) Stop the transfusion immediately
d) Change the IV infusion to normal saline
Answer: c) Stop the transfusion immediately.
Rationale: The client is likely experiencing a transfusion reaction. The
first priority is to stop the transfusion immediately to prevent further
complications, followed by notifying the healthcare provider and taking
