1. Which of the following is the most important assessment for a
nurse to perform when caring for a patient who has had abdominal
surgery?
• a) Monitoring the level of consciousness.
• b) Assessing the patient’s pain level.
• c) Monitoring vital signs for signs of shock.
• d) Inspecting the incision site for signs of infection.
Answer: c) Monitoring vital signs for signs of shock.
• Rationale: Post-surgical patients, particularly after abdominal
surgery, are at risk for hypovolemic shock due to blood loss,
infection, or dehydration. Monitoring vital signs helps detect early
signs of shock, such as hypotension, tachycardia, or changes in
respiratory rate.
2. A nurse is caring for a client with chronic renal failure. Which of the
following interventions would the nurse expect to be part of the
client’s care plan?
• a) Fluid restriction.
• b) Increased dietary sodium.
• c) Administering antibiotics prophylactically.
• d) High-protein diet.
Answer: a) Fluid restriction.
• Rationale: Clients with chronic renal failure have impaired kidney
function, leading to fluid retention. A fluid restriction is typically
part of the care plan to avoid exacerbating fluid overload, which
can lead to hypertension, heart failure, and pulmonary edema.
,3. A nurse is caring for a patient with a diagnosis of acute pancreatitis.
Which of the following interventions is the nurse’s priority?
• a) Administering prescribed antibiotics.
• b) Preparing the patient for surgery.
• c) Providing pain management.
• d) Promoting ambulation.
Answer: c) Providing pain management.
• Rationale: Acute pancreatitis often causes severe abdominal pain.
Pain management is the priority to provide comfort and support
the patient’s healing process. Other interventions like antibiotics
or surgery may be required depending on the underlying cause of
pancreatitis, but pain relief is the first priority.
4. Which of the following is an expected finding in a patient with left-
sided heart failure?
• a) Jaundice.
• b) Pulmonary congestion.
• c) Jugular vein distention.
• d) Peripheral edema.
Answer: b) Pulmonary congestion.
• Rationale: Left-sided heart failure results in pulmonary congestion
because the left ventricle is unable to pump blood efficiently,
causing blood to back up into the lungs. This can lead to
symptoms such as dyspnea, crackles, and decreased oxygenation.
5. A nurse is caring for a patient with deep vein thrombosis (DVT).
Which of the following interventions should be avoided?
, • a) Encouraging early ambulation.
• b) Administering anticoagulants as prescribed.
• c) Applying compression stockings.
• d) Massaging the affected limb.
Answer: d) Massaging the affected limb.
• Rationale: Massaging the affected limb can dislodge the clot,
leading to a potentially fatal embolism. Other interventions, such
as encouraging ambulation and administering anticoagulants, are
appropriate for managing DVT.
6. Which of the following findings would indicate that a patient’s
blood transfusion is causing a reaction?
• a) Increased heart rate and fever.
• b) Hypotension and rash.
• c) Decreased respiratory rate and headache.
• d) Weight gain and dizziness.
Answer: b) Hypotension and rash.
• Rationale: Hypotension and rash are common signs of an allergic
or anaphylactic transfusion reaction. Other signs include fever,
chills, and back pain. The nurse should stop the transfusion and
notify the healthcare provider immediately if any of these
symptoms occur.
7. Which of the following is the priority nursing intervention for a
patient with a diagnosis of a cerebrovascular accident (CVA) or stroke?
• a) Encouraging the patient to perform active range-of-motion
exercises.
nurse to perform when caring for a patient who has had abdominal
surgery?
• a) Monitoring the level of consciousness.
• b) Assessing the patient’s pain level.
• c) Monitoring vital signs for signs of shock.
• d) Inspecting the incision site for signs of infection.
Answer: c) Monitoring vital signs for signs of shock.
• Rationale: Post-surgical patients, particularly after abdominal
surgery, are at risk for hypovolemic shock due to blood loss,
infection, or dehydration. Monitoring vital signs helps detect early
signs of shock, such as hypotension, tachycardia, or changes in
respiratory rate.
2. A nurse is caring for a client with chronic renal failure. Which of the
following interventions would the nurse expect to be part of the
client’s care plan?
• a) Fluid restriction.
• b) Increased dietary sodium.
• c) Administering antibiotics prophylactically.
• d) High-protein diet.
Answer: a) Fluid restriction.
• Rationale: Clients with chronic renal failure have impaired kidney
function, leading to fluid retention. A fluid restriction is typically
part of the care plan to avoid exacerbating fluid overload, which
can lead to hypertension, heart failure, and pulmonary edema.
,3. A nurse is caring for a patient with a diagnosis of acute pancreatitis.
Which of the following interventions is the nurse’s priority?
• a) Administering prescribed antibiotics.
• b) Preparing the patient for surgery.
• c) Providing pain management.
• d) Promoting ambulation.
Answer: c) Providing pain management.
• Rationale: Acute pancreatitis often causes severe abdominal pain.
Pain management is the priority to provide comfort and support
the patient’s healing process. Other interventions like antibiotics
or surgery may be required depending on the underlying cause of
pancreatitis, but pain relief is the first priority.
4. Which of the following is an expected finding in a patient with left-
sided heart failure?
• a) Jaundice.
• b) Pulmonary congestion.
• c) Jugular vein distention.
• d) Peripheral edema.
Answer: b) Pulmonary congestion.
• Rationale: Left-sided heart failure results in pulmonary congestion
because the left ventricle is unable to pump blood efficiently,
causing blood to back up into the lungs. This can lead to
symptoms such as dyspnea, crackles, and decreased oxygenation.
5. A nurse is caring for a patient with deep vein thrombosis (DVT).
Which of the following interventions should be avoided?
, • a) Encouraging early ambulation.
• b) Administering anticoagulants as prescribed.
• c) Applying compression stockings.
• d) Massaging the affected limb.
Answer: d) Massaging the affected limb.
• Rationale: Massaging the affected limb can dislodge the clot,
leading to a potentially fatal embolism. Other interventions, such
as encouraging ambulation and administering anticoagulants, are
appropriate for managing DVT.
6. Which of the following findings would indicate that a patient’s
blood transfusion is causing a reaction?
• a) Increased heart rate and fever.
• b) Hypotension and rash.
• c) Decreased respiratory rate and headache.
• d) Weight gain and dizziness.
Answer: b) Hypotension and rash.
• Rationale: Hypotension and rash are common signs of an allergic
or anaphylactic transfusion reaction. Other signs include fever,
chills, and back pain. The nurse should stop the transfusion and
notify the healthcare provider immediately if any of these
symptoms occur.
7. Which of the following is the priority nursing intervention for a
patient with a diagnosis of a cerebrovascular accident (CVA) or stroke?
• a) Encouraging the patient to perform active range-of-motion
exercises.
