1. A patient with pneumonia is being discharged. Which of the
following instructions should the nurse include in the discharge
teaching?
A) "You can stop taking antibiotics once you feel better."
B) "Take your antibiotics until they are all finished, even if you feel
better."
C) "It is okay to exercise as soon as you feel tired."
D) "You should rest in bed for at least one week."
Answer: B) "Take your antibiotics until they are all finished, even if
you feel better."
Rationale: Antibiotics should always be completed as prescribed to
ensure the infection is fully treated and to prevent the development of
antibiotic resistance.
2. A nurse is caring for a client who has a deep vein thrombosis (DVT).
The nurse should identify which of the following as the priority
intervention?
A) Administering anticoagulants as prescribed
B) Elevating the affected leg
C) Applying warm compresses to the affected leg
D) Encouraging the client to ambulate
Answer: A) Administering anticoagulants as prescribed
Rationale: The primary intervention for a DVT is preventing the clot
from becoming larger or breaking off and causing a pulmonary
embolism. Anticoagulants reduce the risk of clot progression.
,3. A nurse is caring for a patient following a cholecystectomy. Which of
the following is a priority in the post-operative care?
A) Ensuring the patient avoids coughing or deep breathing
B) Encouraging the patient to ambulate as soon as possible
C) Administering analgesics before meals
D) Encouraging the patient to eat a high-fat diet to promote digestion
Answer: B) Encouraging the patient to ambulate as soon as possible
Rationale: Early ambulation helps prevent complications like deep vein
thrombosis (DVT), promotes circulation, and aids in the patient’s overall
recovery.
4. A nurse is caring for a patient with chronic renal failure. Which of
the following findings should the nurse report to the healthcare
provider?
A) Serum potassium level of 5.0 mEq/L
B) Serum creatinine level of 1.2 mg/dL
C) Weight gain of 3 lbs in 24 hours
D) Blood urea nitrogen (BUN) of 15 mg/dL
Answer: C) Weight gain of 3 lbs in 24 hours
Rationale: A sudden weight gain in a patient with renal failure can
indicate fluid retention, which can lead to complications such as
pulmonary edema or heart failure.
, 5. A nurse is caring for a client with a history of chronic obstructive
pulmonary disease (COPD) who is receiving oxygen therapy. Which of
the following is the priority nursing action?
A) Monitoring oxygen saturation levels regularly
B) Ensuring the oxygen flow rate is set to 2 L/min
C) Teaching the client pursed-lip breathing techniques
D) Ensuring the oxygen delivery device is positioned properly
Answer: A) Monitoring oxygen saturation levels regularly
Rationale: The priority for COPD patients on oxygen therapy is
maintaining adequate oxygen saturation levels, which should be
monitored to ensure proper oxygenation without causing oxygen
toxicity or hypercapnia.
6. A patient with a history of hypertension is admitted with acute
chest pain. Which of the following is the most important intervention
for the nurse to implement first?
A) Administer morphine sulfate as prescribed
B) Administer nitroglycerin as prescribed
C) Perform an electrocardiogram (ECG)
D) Obtain a 12-lead ECG
Answer: C) Perform an electrocardiogram (ECG)
Rationale: The first priority in acute chest pain is to assess for
myocardial ischemia or infarction using an ECG. This is necessary to
guide further treatment.
following instructions should the nurse include in the discharge
teaching?
A) "You can stop taking antibiotics once you feel better."
B) "Take your antibiotics until they are all finished, even if you feel
better."
C) "It is okay to exercise as soon as you feel tired."
D) "You should rest in bed for at least one week."
Answer: B) "Take your antibiotics until they are all finished, even if
you feel better."
Rationale: Antibiotics should always be completed as prescribed to
ensure the infection is fully treated and to prevent the development of
antibiotic resistance.
2. A nurse is caring for a client who has a deep vein thrombosis (DVT).
The nurse should identify which of the following as the priority
intervention?
A) Administering anticoagulants as prescribed
B) Elevating the affected leg
C) Applying warm compresses to the affected leg
D) Encouraging the client to ambulate
Answer: A) Administering anticoagulants as prescribed
Rationale: The primary intervention for a DVT is preventing the clot
from becoming larger or breaking off and causing a pulmonary
embolism. Anticoagulants reduce the risk of clot progression.
,3. A nurse is caring for a patient following a cholecystectomy. Which of
the following is a priority in the post-operative care?
A) Ensuring the patient avoids coughing or deep breathing
B) Encouraging the patient to ambulate as soon as possible
C) Administering analgesics before meals
D) Encouraging the patient to eat a high-fat diet to promote digestion
Answer: B) Encouraging the patient to ambulate as soon as possible
Rationale: Early ambulation helps prevent complications like deep vein
thrombosis (DVT), promotes circulation, and aids in the patient’s overall
recovery.
4. A nurse is caring for a patient with chronic renal failure. Which of
the following findings should the nurse report to the healthcare
provider?
A) Serum potassium level of 5.0 mEq/L
B) Serum creatinine level of 1.2 mg/dL
C) Weight gain of 3 lbs in 24 hours
D) Blood urea nitrogen (BUN) of 15 mg/dL
Answer: C) Weight gain of 3 lbs in 24 hours
Rationale: A sudden weight gain in a patient with renal failure can
indicate fluid retention, which can lead to complications such as
pulmonary edema or heart failure.
, 5. A nurse is caring for a client with a history of chronic obstructive
pulmonary disease (COPD) who is receiving oxygen therapy. Which of
the following is the priority nursing action?
A) Monitoring oxygen saturation levels regularly
B) Ensuring the oxygen flow rate is set to 2 L/min
C) Teaching the client pursed-lip breathing techniques
D) Ensuring the oxygen delivery device is positioned properly
Answer: A) Monitoring oxygen saturation levels regularly
Rationale: The priority for COPD patients on oxygen therapy is
maintaining adequate oxygen saturation levels, which should be
monitored to ensure proper oxygenation without causing oxygen
toxicity or hypercapnia.
6. A patient with a history of hypertension is admitted with acute
chest pain. Which of the following is the most important intervention
for the nurse to implement first?
A) Administer morphine sulfate as prescribed
B) Administer nitroglycerin as prescribed
C) Perform an electrocardiogram (ECG)
D) Obtain a 12-lead ECG
Answer: C) Perform an electrocardiogram (ECG)
Rationale: The first priority in acute chest pain is to assess for
myocardial ischemia or infarction using an ECG. This is necessary to
guide further treatment.
