1. A nurse is caring for a client who has a history of heart failure and is
admitted with shortness of breath and weight gain. Which of the
following findings should the nurse report to the provider
immediately?
a) Heart rate of 88/min
b) Blood pressure of 120/78 mm Hg
c) Weight gain of 3 lbs over 2 days
d) Respiratory rate of 18/min
Answer: c) Weight gain of 3 lbs over 2 days
Rationale: A rapid weight gain of 2-3 pounds in 1-2 days may indicate
fluid retention and worsening heart failure. This should be reported
immediately to the provider for further assessment and potential
intervention.
2. A nurse is providing discharge instructions to a client who has a new
prescription for warfarin. Which of the following statements by the
client indicates the need for further teaching?
a) "I will use a soft toothbrush when brushing my teeth."
b) "I should avoid eating foods high in vitamin K."
c) "I will take my medication at the same time every day."
d) "I can stop taking the medication if I feel better."
Answer: d) "I can stop taking the medication if I feel better."
Rationale: Warfarin is a long-term medication used to prevent blood
clots, and it should not be discontinued without consulting a provider.
Stopping the medication could increase the risk of clot formation.
,3. A nurse is caring for a client who is post-operative following a hip
replacement surgery. Which of the following actions should the nurse
take to prevent deep vein thrombosis (DVT)?
a) Elevate the client's legs above the level of the heart.
b) Encourage the client to perform leg exercises every 2 hours.
c) Place the client on bed rest for 48 hours.
d) Apply heat compresses to the affected leg.
Answer: b) Encourage the client to perform leg exercises every 2 hours.
Rationale: Leg exercises (ankle pumps, foot circles) help increase
circulation and prevent venous stasis, which is a risk factor for DVT.
Encouraging mobility is key to DVT prevention.
4. A nurse is assessing a client with a history of chronic obstructive
pulmonary disease (COPD) who is receiving oxygen therapy. Which of
the following findings is most concerning?
a) Oxygen saturation of 90%
b) Respiratory rate of 22/min
c) Client is using accessory muscles to breathe
d) Crackles in the lungs upon auscultation
Answer: c) Client is using accessory muscles to breathe
Rationale: The use of accessory muscles indicates increased work of
breathing and respiratory distress, which is a concern in COPD clients.
This finding should be reported immediately to the provider.
5. A nurse is teaching a client with diabetes mellitus about managing
their blood sugar levels. Which of the following statements indicates
the need for further teaching?
, a) "I will monitor my blood sugar before meals and at bedtime."
b) "I can eat my usual meals, as long as I take extra insulin."
c) "I will keep a snack with me in case my blood sugar gets too low."
d) "I will notify my provider if I experience any signs of high blood
sugar."
Answer: b) "I can eat my usual meals, as long as I take extra insulin."
Rationale: Insulin should be adjusted based on carbohydrate intake and
blood glucose levels, not just as a response to eating “usual meals.”
Meal planning and appropriate insulin management are key in diabetes
management.
6. A nurse is caring for a client with a newly inserted chest tube.
Which of the following actions should the nurse take to ensure the
chest tube is functioning properly?
a) Clamp the chest tube during transport.
b) Keep the drainage system upright at all times.
c) Observe for fluctuation in the water-seal chamber with inspiration
and expiration.
d) Allow the client to change position frequently.
Answer: c) Observe for fluctuation in the water-seal chamber with
inspiration and expiration.
Rationale: The fluctuation (or "tidaling") in the water-seal chamber
indicates that the chest tube is functioning properly and is in
communication with the pleural space. If there is no fluctuation, it could
indicate that the tube is blocked.
admitted with shortness of breath and weight gain. Which of the
following findings should the nurse report to the provider
immediately?
a) Heart rate of 88/min
b) Blood pressure of 120/78 mm Hg
c) Weight gain of 3 lbs over 2 days
d) Respiratory rate of 18/min
Answer: c) Weight gain of 3 lbs over 2 days
Rationale: A rapid weight gain of 2-3 pounds in 1-2 days may indicate
fluid retention and worsening heart failure. This should be reported
immediately to the provider for further assessment and potential
intervention.
2. A nurse is providing discharge instructions to a client who has a new
prescription for warfarin. Which of the following statements by the
client indicates the need for further teaching?
a) "I will use a soft toothbrush when brushing my teeth."
b) "I should avoid eating foods high in vitamin K."
c) "I will take my medication at the same time every day."
d) "I can stop taking the medication if I feel better."
Answer: d) "I can stop taking the medication if I feel better."
Rationale: Warfarin is a long-term medication used to prevent blood
clots, and it should not be discontinued without consulting a provider.
Stopping the medication could increase the risk of clot formation.
,3. A nurse is caring for a client who is post-operative following a hip
replacement surgery. Which of the following actions should the nurse
take to prevent deep vein thrombosis (DVT)?
a) Elevate the client's legs above the level of the heart.
b) Encourage the client to perform leg exercises every 2 hours.
c) Place the client on bed rest for 48 hours.
d) Apply heat compresses to the affected leg.
Answer: b) Encourage the client to perform leg exercises every 2 hours.
Rationale: Leg exercises (ankle pumps, foot circles) help increase
circulation and prevent venous stasis, which is a risk factor for DVT.
Encouraging mobility is key to DVT prevention.
4. A nurse is assessing a client with a history of chronic obstructive
pulmonary disease (COPD) who is receiving oxygen therapy. Which of
the following findings is most concerning?
a) Oxygen saturation of 90%
b) Respiratory rate of 22/min
c) Client is using accessory muscles to breathe
d) Crackles in the lungs upon auscultation
Answer: c) Client is using accessory muscles to breathe
Rationale: The use of accessory muscles indicates increased work of
breathing and respiratory distress, which is a concern in COPD clients.
This finding should be reported immediately to the provider.
5. A nurse is teaching a client with diabetes mellitus about managing
their blood sugar levels. Which of the following statements indicates
the need for further teaching?
, a) "I will monitor my blood sugar before meals and at bedtime."
b) "I can eat my usual meals, as long as I take extra insulin."
c) "I will keep a snack with me in case my blood sugar gets too low."
d) "I will notify my provider if I experience any signs of high blood
sugar."
Answer: b) "I can eat my usual meals, as long as I take extra insulin."
Rationale: Insulin should be adjusted based on carbohydrate intake and
blood glucose levels, not just as a response to eating “usual meals.”
Meal planning and appropriate insulin management are key in diabetes
management.
6. A nurse is caring for a client with a newly inserted chest tube.
Which of the following actions should the nurse take to ensure the
chest tube is functioning properly?
a) Clamp the chest tube during transport.
b) Keep the drainage system upright at all times.
c) Observe for fluctuation in the water-seal chamber with inspiration
and expiration.
d) Allow the client to change position frequently.
Answer: c) Observe for fluctuation in the water-seal chamber with
inspiration and expiration.
Rationale: The fluctuation (or "tidaling") in the water-seal chamber
indicates that the chest tube is functioning properly and is in
communication with the pleural space. If there is no fluctuation, it could
indicate that the tube is blocked.
