1. Which of the following is the priority nursing intervention for a
patient with a new diagnosis of heart failure?
A) Monitor vital signs every 4 hours
B) Educate the patient about the importance of daily weight
measurement
C) Assist the patient with daily ambulation exercises
D) Maintain a strict fluid restriction
Answer: B) Educate the patient about the importance of daily weight
measurement
Rationale: The priority intervention is to educate the patient on daily
weight measurement. Rapid weight gain can indicate fluid retention,
which is critical in the management of heart failure. Regular monitoring
can help detect exacerbations early.
2. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). Which of the following is the most appropriate
nursing action when administering oxygen therapy to this patient?
A) Administer oxygen at a high flow rate to promote adequate
oxygenation.
B) Ensure the oxygen flow rate does not exceed 2 liters per minute.
C) Encourage the patient to breathe rapidly to improve oxygen intake.
D) Place the patient in a flat, supine position during oxygen
administration.
Answer: B) Ensure the oxygen flow rate does not exceed 2 liters per
minute.
Rationale: COPD patients have a reduced sensitivity to high oxygen
levels, and too much oxygen can depress their respiratory drive.
,Therefore, oxygen should be administered at a low flow rate to prevent
carbon dioxide retention.
3. A nurse is caring for a patient with a history of deep vein
thrombosis (DVT) who is prescribed warfarin (Coumadin). Which of
the following laboratory tests should be monitored regularly?
A) Hemoglobin and hematocrit
B) Prothrombin time (PT) and international normalized ratio (INR)
C) Serum potassium and sodium levels
D) Blood urea nitrogen (BUN) and creatinine levels
Answer: B) Prothrombin time (PT) and international normalized ratio
(INR)
Rationale: Warfarin is an anticoagulant, and it affects clotting factors.
Monitoring the PT and INR helps to assess the effectiveness of the
medication and ensure the patient’s blood does not become too thin.
4. A nurse is caring for a client with acute pancreatitis. Which of the
following findings would be most concerning for this patient?
A) Abdominal tenderness and distention
B) Decreased urine output
C) Elevated serum amylase and lipase
D) Low-grade fever
Answer: B) Decreased urine output
Rationale: Decreased urine output is concerning because it can indicate
acute kidney injury (AKI), which is a potential complication of acute
pancreatitis due to hypovolemia or systemic inflammation.
, 5. A nurse is assessing a patient with chronic kidney disease (CKD).
Which of the following is the most common cause of CKD?
A) Hypertension
B) Renal artery stenosis
C) Glomerulonephritis
D) Diabetes mellitus
Answer: D) Diabetes mellitus
Rationale: Diabetes mellitus is the leading cause of chronic kidney
disease, followed by hypertension. Chronic high blood sugar levels
damage the kidneys over time, impairing their function.
6. A nurse is caring for a patient post-thyroidectomy. Which of the
following should the nurse assess for in the first 24 hours after
surgery?
A) Increased appetite and thirst
B) Hypocalcemia and tetany
C) Swelling in the lower extremities
D) Increased urinary output
Answer: B) Hypocalcemia and tetany
Rationale: After a thyroidectomy, the parathyroid glands, which
regulate calcium, may be affected. Hypocalcemia can lead to symptoms
like tetany (muscle twitching and spasms), which should be closely
monitored.
patient with a new diagnosis of heart failure?
A) Monitor vital signs every 4 hours
B) Educate the patient about the importance of daily weight
measurement
C) Assist the patient with daily ambulation exercises
D) Maintain a strict fluid restriction
Answer: B) Educate the patient about the importance of daily weight
measurement
Rationale: The priority intervention is to educate the patient on daily
weight measurement. Rapid weight gain can indicate fluid retention,
which is critical in the management of heart failure. Regular monitoring
can help detect exacerbations early.
2. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). Which of the following is the most appropriate
nursing action when administering oxygen therapy to this patient?
A) Administer oxygen at a high flow rate to promote adequate
oxygenation.
B) Ensure the oxygen flow rate does not exceed 2 liters per minute.
C) Encourage the patient to breathe rapidly to improve oxygen intake.
D) Place the patient in a flat, supine position during oxygen
administration.
Answer: B) Ensure the oxygen flow rate does not exceed 2 liters per
minute.
Rationale: COPD patients have a reduced sensitivity to high oxygen
levels, and too much oxygen can depress their respiratory drive.
,Therefore, oxygen should be administered at a low flow rate to prevent
carbon dioxide retention.
3. A nurse is caring for a patient with a history of deep vein
thrombosis (DVT) who is prescribed warfarin (Coumadin). Which of
the following laboratory tests should be monitored regularly?
A) Hemoglobin and hematocrit
B) Prothrombin time (PT) and international normalized ratio (INR)
C) Serum potassium and sodium levels
D) Blood urea nitrogen (BUN) and creatinine levels
Answer: B) Prothrombin time (PT) and international normalized ratio
(INR)
Rationale: Warfarin is an anticoagulant, and it affects clotting factors.
Monitoring the PT and INR helps to assess the effectiveness of the
medication and ensure the patient’s blood does not become too thin.
4. A nurse is caring for a client with acute pancreatitis. Which of the
following findings would be most concerning for this patient?
A) Abdominal tenderness and distention
B) Decreased urine output
C) Elevated serum amylase and lipase
D) Low-grade fever
Answer: B) Decreased urine output
Rationale: Decreased urine output is concerning because it can indicate
acute kidney injury (AKI), which is a potential complication of acute
pancreatitis due to hypovolemia or systemic inflammation.
, 5. A nurse is assessing a patient with chronic kidney disease (CKD).
Which of the following is the most common cause of CKD?
A) Hypertension
B) Renal artery stenosis
C) Glomerulonephritis
D) Diabetes mellitus
Answer: D) Diabetes mellitus
Rationale: Diabetes mellitus is the leading cause of chronic kidney
disease, followed by hypertension. Chronic high blood sugar levels
damage the kidneys over time, impairing their function.
6. A nurse is caring for a patient post-thyroidectomy. Which of the
following should the nurse assess for in the first 24 hours after
surgery?
A) Increased appetite and thirst
B) Hypocalcemia and tetany
C) Swelling in the lower extremities
D) Increased urinary output
Answer: B) Hypocalcemia and tetany
Rationale: After a thyroidectomy, the parathyroid glands, which
regulate calcium, may be affected. Hypocalcemia can lead to symptoms
like tetany (muscle twitching and spasms), which should be closely
monitored.
