1. A nurse is caring for a client with a diagnosis of acute pancreatitis.
Which of the following interventions should the nurse prioritize?
A) Administering oral fluids B) Encouraging a high-protein, low-fat diet
C) Withholding oral intake D) Providing a warm compress to the
abdomen
Answer: C) Withholding oral intake
Rationale: In acute pancreatitis, the pancreas is inflamed, and
stimulating it with food or liquids can exacerbate the condition. Oral
intake is typically withheld until the inflammation subsides, and
hydration is provided intravenously.
2. A nurse is preparing to care for a client with a myocardial infarction
(MI). Which of the following medications should the nurse expect the
healthcare provider to order first?
A) Beta-blockers B) Thrombolytics C) Anticoagulants D) Diuretics
Answer: B) Thrombolytics
Rationale: Thrombolytics are used in the acute phase of an MI to break
down clots in the coronary arteries, restoring blood flow to the heart.
They are typically administered within the first few hours of onset.
3. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is experiencing dyspnea. Which of the following
interventions should the nurse implement first?
A) Administering oxygen therapy B) Increasing the client's fluid intake C)
Encouraging the client to cough and deep breathe D) Positioning the
client in a high-Fowler's position
,Answer: D) Positioning the client in a high-Fowler's position
Rationale: High-Fowler's position helps to maximize lung expansion and
improve oxygenation. It is the first intervention to provide relief to a
client experiencing dyspnea.
4. A nurse is caring for a client with a diagnosis of liver cirrhosis.
Which of the following laboratory findings is most likely to be present
in this client?
A) Increased hemoglobin levels B) Decreased serum albumin levels C)
Elevated white blood cell count D) Increased blood urea nitrogen (BUN)
Answer: B) Decreased serum albumin levels
Rationale: Liver cirrhosis affects the liver's ability to synthesize proteins,
including albumin. Decreased serum albumin levels are common in
clients with cirrhosis.
5. A nurse is assessing a client with a diagnosis of congestive heart
failure (CHF). Which of the following findings should the nurse expect
to find?
A) Bradycardia B) Jugular vein distention C) Hyperactive bowel sounds
D) Hypotension
Answer: B) Jugular vein distention
Rationale: Jugular vein distention is a common sign of fluid retention in
clients with CHF. The right side of the heart becomes congested, leading
to increased pressure in the veins.
, 6. A nurse is caring for a client with a history of stroke who has right-
sided paralysis. Which of the following actions should the nurse take
to promote the client’s independence in activities of daily living?
A) Assist the client with all activities to ensure safety B) Encourage the
client to perform activities with the left hand C) Perform passive range-
of-motion exercises on the right side D) Provide adaptive equipment for
tasks that require the right hand
Answer: B) Encourage the client to perform activities with the left hand
Rationale: Encouraging the client to use the unaffected side (left hand)
promotes independence and strengthens motor skills. While safety is
important, promoting independence is key in rehabilitation.
7. A nurse is caring for a client who has undergone a total hip
replacement. Which of the following should the nurse include in the
postoperative plan of care?
A) Avoid using a pillow between the legs when turning B) Limit weight-
bearing on the affected leg as instructed C) Encourage bending the hip
to a 90-degree angle D) Position the client on the affected hip to
prevent dislocation
Answer: B) Limit weight-bearing on the affected leg as instructed
Rationale: After a total hip replacement, the client must follow specific
weight-bearing precautions to avoid complications such as dislocation
or improper healing of the joint.
8. A nurse is caring for a client who is receiving warfarin therapy.
Which of the following lab tests should the nurse monitor?
Which of the following interventions should the nurse prioritize?
A) Administering oral fluids B) Encouraging a high-protein, low-fat diet
C) Withholding oral intake D) Providing a warm compress to the
abdomen
Answer: C) Withholding oral intake
Rationale: In acute pancreatitis, the pancreas is inflamed, and
stimulating it with food or liquids can exacerbate the condition. Oral
intake is typically withheld until the inflammation subsides, and
hydration is provided intravenously.
2. A nurse is preparing to care for a client with a myocardial infarction
(MI). Which of the following medications should the nurse expect the
healthcare provider to order first?
A) Beta-blockers B) Thrombolytics C) Anticoagulants D) Diuretics
Answer: B) Thrombolytics
Rationale: Thrombolytics are used in the acute phase of an MI to break
down clots in the coronary arteries, restoring blood flow to the heart.
They are typically administered within the first few hours of onset.
3. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is experiencing dyspnea. Which of the following
interventions should the nurse implement first?
A) Administering oxygen therapy B) Increasing the client's fluid intake C)
Encouraging the client to cough and deep breathe D) Positioning the
client in a high-Fowler's position
,Answer: D) Positioning the client in a high-Fowler's position
Rationale: High-Fowler's position helps to maximize lung expansion and
improve oxygenation. It is the first intervention to provide relief to a
client experiencing dyspnea.
4. A nurse is caring for a client with a diagnosis of liver cirrhosis.
Which of the following laboratory findings is most likely to be present
in this client?
A) Increased hemoglobin levels B) Decreased serum albumin levels C)
Elevated white blood cell count D) Increased blood urea nitrogen (BUN)
Answer: B) Decreased serum albumin levels
Rationale: Liver cirrhosis affects the liver's ability to synthesize proteins,
including albumin. Decreased serum albumin levels are common in
clients with cirrhosis.
5. A nurse is assessing a client with a diagnosis of congestive heart
failure (CHF). Which of the following findings should the nurse expect
to find?
A) Bradycardia B) Jugular vein distention C) Hyperactive bowel sounds
D) Hypotension
Answer: B) Jugular vein distention
Rationale: Jugular vein distention is a common sign of fluid retention in
clients with CHF. The right side of the heart becomes congested, leading
to increased pressure in the veins.
, 6. A nurse is caring for a client with a history of stroke who has right-
sided paralysis. Which of the following actions should the nurse take
to promote the client’s independence in activities of daily living?
A) Assist the client with all activities to ensure safety B) Encourage the
client to perform activities with the left hand C) Perform passive range-
of-motion exercises on the right side D) Provide adaptive equipment for
tasks that require the right hand
Answer: B) Encourage the client to perform activities with the left hand
Rationale: Encouraging the client to use the unaffected side (left hand)
promotes independence and strengthens motor skills. While safety is
important, promoting independence is key in rehabilitation.
7. A nurse is caring for a client who has undergone a total hip
replacement. Which of the following should the nurse include in the
postoperative plan of care?
A) Avoid using a pillow between the legs when turning B) Limit weight-
bearing on the affected leg as instructed C) Encourage bending the hip
to a 90-degree angle D) Position the client on the affected hip to
prevent dislocation
Answer: B) Limit weight-bearing on the affected leg as instructed
Rationale: After a total hip replacement, the client must follow specific
weight-bearing precautions to avoid complications such as dislocation
or improper healing of the joint.
8. A nurse is caring for a client who is receiving warfarin therapy.
Which of the following lab tests should the nurse monitor?
