1. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is experiencing shortness of breath. Which of the
following interventions is most appropriate to improve the client’s
respiratory status?
A) Administer oxygen at 10 L/min via a non-rebreather mask.
B) Position the client in a high Fowler's position.
C) Encourage the client to lie flat to maximize lung expansion.
D) Encourage the client to take rapid, shallow breaths.
Answer: B) Position the client in a high Fowler's position.
Rationale: In COPD, positioning the client in a high Fowler's position
helps to expand the lungs and promotes easier breathing. This position
reduces pressure on the diaphragm, increasing lung capacity.
Administering oxygen at a high flow rate (as in option A) may not be
appropriate for COPD patients, as it can suppress respiratory drive.
Encouraging rapid, shallow breathing or lying flat would likely worsen
breathing difficulties.
2. A nurse is assessing a newly admitted client who is experiencing
severe nausea and vomiting. The nurse notes the client’s blood
pressure is 90/60 mmHg, and heart rate is 112 bpm. What should the
nurse prioritize in the care of this client?
A) Administer an antiemetic as prescribed.
B) Administer IV fluids to correct hypovolemia.
C) Monitor the client’s urine output.
D) Perform a thorough abdominal assessment.
Answer: B) Administer IV fluids to correct hypovolemia.
,Rationale: The client is showing signs of hypovolemia (low blood
pressure and elevated heart rate) likely caused by fluid loss from
vomiting. Administering IV fluids is the priority to stabilize the client’s
circulatory volume. While antiemetics (A) may help alleviate nausea,
fluid resuscitation is more urgent in this situation. Monitoring urine
output (C) is important but is secondary to correcting the fluid deficit.
3. A nurse is educating a client with hypertension about the
importance of medication adherence. Which statement by the client
indicates a need for further teaching?
A) "I will take my medication every morning as prescribed."
B) "I will stop my medication if I feel fine and my blood pressure is
normal."
C) "I should monitor my blood pressure regularly at home."
D) "I will follow a low-sodium diet to help manage my blood pressure."
Answer: B) "I will stop my medication if I feel fine and my blood
pressure is normal."
Rationale: Clients with hypertension should understand that even if
they feel fine or their blood pressure is normal, stopping medication can
lead to uncontrolled hypertension and complications. Medication
adherence is crucial, and blood pressure monitoring at home is
recommended (C). A low-sodium diet (D) is also beneficial in managing
hypertension.
4. A nurse is caring for a client who is 24 hours post-operative
following a cholecystectomy. Which of the following findings requires
immediate attention?
, A) The client is reporting mild pain at the surgical site.
B) The client’s temperature is 100°F (37.8°C).
C) The client’s wound site is red, warm, and has purulent drainage.
D) The client has minimal nausea and is able to take fluids.
Answer: C) The client’s wound site is red, warm, and has purulent
drainage.
Rationale: Signs of infection, such as redness, warmth, and purulent
drainage at the surgical site, require immediate intervention. A low-
grade fever (100°F) may be expected in the first 24 hours after surgery,
and mild pain is also typical. However, purulent drainage indicates
possible infection and needs further evaluation.
5. A client with type 1 diabetes asks the nurse why they should not
skip breakfast, even if they are not hungry. Which response by the
nurse is most appropriate?
A) "Skipping breakfast will help you lose weight and control your blood
sugar."
B) "Skipping meals can lead to low blood sugar, which can be
dangerous."
C) "You should skip breakfast if you want to avoid high blood sugar later
in the day."
D) "Your insulin regimen is designed to work better when you eat
regularly."
Answer: B) "Skipping meals can lead to low blood sugar, which can be
dangerous."
Rationale: For individuals with type 1 diabetes, skipping meals can
cause blood glucose to drop too low, potentially leading to
hypoglycemia. Regular eating is crucial to maintain balanced blood
disease (COPD) who is experiencing shortness of breath. Which of the
following interventions is most appropriate to improve the client’s
respiratory status?
A) Administer oxygen at 10 L/min via a non-rebreather mask.
B) Position the client in a high Fowler's position.
C) Encourage the client to lie flat to maximize lung expansion.
D) Encourage the client to take rapid, shallow breaths.
Answer: B) Position the client in a high Fowler's position.
Rationale: In COPD, positioning the client in a high Fowler's position
helps to expand the lungs and promotes easier breathing. This position
reduces pressure on the diaphragm, increasing lung capacity.
Administering oxygen at a high flow rate (as in option A) may not be
appropriate for COPD patients, as it can suppress respiratory drive.
Encouraging rapid, shallow breathing or lying flat would likely worsen
breathing difficulties.
2. A nurse is assessing a newly admitted client who is experiencing
severe nausea and vomiting. The nurse notes the client’s blood
pressure is 90/60 mmHg, and heart rate is 112 bpm. What should the
nurse prioritize in the care of this client?
A) Administer an antiemetic as prescribed.
B) Administer IV fluids to correct hypovolemia.
C) Monitor the client’s urine output.
D) Perform a thorough abdominal assessment.
Answer: B) Administer IV fluids to correct hypovolemia.
,Rationale: The client is showing signs of hypovolemia (low blood
pressure and elevated heart rate) likely caused by fluid loss from
vomiting. Administering IV fluids is the priority to stabilize the client’s
circulatory volume. While antiemetics (A) may help alleviate nausea,
fluid resuscitation is more urgent in this situation. Monitoring urine
output (C) is important but is secondary to correcting the fluid deficit.
3. A nurse is educating a client with hypertension about the
importance of medication adherence. Which statement by the client
indicates a need for further teaching?
A) "I will take my medication every morning as prescribed."
B) "I will stop my medication if I feel fine and my blood pressure is
normal."
C) "I should monitor my blood pressure regularly at home."
D) "I will follow a low-sodium diet to help manage my blood pressure."
Answer: B) "I will stop my medication if I feel fine and my blood
pressure is normal."
Rationale: Clients with hypertension should understand that even if
they feel fine or their blood pressure is normal, stopping medication can
lead to uncontrolled hypertension and complications. Medication
adherence is crucial, and blood pressure monitoring at home is
recommended (C). A low-sodium diet (D) is also beneficial in managing
hypertension.
4. A nurse is caring for a client who is 24 hours post-operative
following a cholecystectomy. Which of the following findings requires
immediate attention?
, A) The client is reporting mild pain at the surgical site.
B) The client’s temperature is 100°F (37.8°C).
C) The client’s wound site is red, warm, and has purulent drainage.
D) The client has minimal nausea and is able to take fluids.
Answer: C) The client’s wound site is red, warm, and has purulent
drainage.
Rationale: Signs of infection, such as redness, warmth, and purulent
drainage at the surgical site, require immediate intervention. A low-
grade fever (100°F) may be expected in the first 24 hours after surgery,
and mild pain is also typical. However, purulent drainage indicates
possible infection and needs further evaluation.
5. A client with type 1 diabetes asks the nurse why they should not
skip breakfast, even if they are not hungry. Which response by the
nurse is most appropriate?
A) "Skipping breakfast will help you lose weight and control your blood
sugar."
B) "Skipping meals can lead to low blood sugar, which can be
dangerous."
C) "You should skip breakfast if you want to avoid high blood sugar later
in the day."
D) "Your insulin regimen is designed to work better when you eat
regularly."
Answer: B) "Skipping meals can lead to low blood sugar, which can be
dangerous."
Rationale: For individuals with type 1 diabetes, skipping meals can
cause blood glucose to drop too low, potentially leading to
hypoglycemia. Regular eating is crucial to maintain balanced blood
