1. A nurse is caring for a client who has heart failure and is receiving a
diuretic. Which of the following laboratory results should the nurse
monitor?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum chloride
Answer: B) Serum potassium
Rationale: Diuretics, especially loop diuretics like furosemide, can cause
potassium depletion. Monitoring potassium levels is essential to
prevent hypokalemia, which can lead to life-threatening arrhythmias.
2. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is receiving supplemental oxygen. The nurse
notes the client’s oxygen saturation is 92%. Which of the following
actions should the nurse take?
A) Increase the oxygen flow rate.
B) Notify the healthcare provider.
C) Decrease the oxygen flow rate.
D) Assess for signs of hypercapnia.
Answer: C) Decrease the oxygen flow rate
Rationale: Clients with COPD are at risk for carbon dioxide retention,
and high levels of oxygen can further suppress respiratory drive.
Maintaining oxygen saturation within a safe range (88-92%) helps
prevent hypercapnia.
,3. A nurse is preparing to administer an antihypertensive medication
to a client with a blood pressure of 158/96 mmHg. Which of the
following actions should the nurse take before administering the
medication?
A) Assess for orthostatic hypotension
B) Check the client’s blood glucose levels
C) Assess for signs of hyperkalemia
D) Encourage the client to rest before medication administration
Answer: A) Assess for orthostatic hypotension
Rationale: Antihypertensive medications can cause orthostatic
hypotension (a sudden drop in blood pressure when standing). The
nurse should assess for this condition to reduce the risk of falls.
4. A nurse is caring for a postoperative client who is at risk for deep
vein thrombosis (DVT). Which of the following interventions should
the nurse include in the care plan?
A) Encourage the client to remain on bed rest
B) Apply elastic stockings to the client’s legs
C) Limit fluid intake to reduce edema
D) Encourage the client to remain immobile for 24 hours
Answer: B) Apply elastic stockings to the client’s legs
Rationale: Elastic stockings help prevent DVT by promoting venous
return and preventing stasis of blood in the lower extremities. Early
ambulation is also important to prevent DVT.
, 5. A nurse is caring for a client with a diagnosis of diabetes mellitus
who is experiencing hyperglycemia. The nurse should anticipate which
of the following interventions?
A) Administer insulin as prescribed
B) Encourage the client to drink fluids with high sugar content
C) Administer sodium bicarbonate to correct acidosis
D) Restrict the client’s fluid intake
Answer: A) Administer insulin as prescribed
Rationale: Hyperglycemia is managed with insulin therapy. The nurse
should follow the provider's orders for insulin to reduce blood glucose
levels and avoid complications such as diabetic ketoacidosis.
6. A nurse is caring for a client with an exacerbation of asthma. Which
of the following findings should the nurse report immediately to the
healthcare provider?
A) Decreased peak flow readings
B) Wheezing with exhalation
C) Use of accessory muscles for breathing
D) Oxygen saturation of 94%
Answer: C) Use of accessory muscles for breathing
Rationale: The use of accessory muscles for breathing indicates severe
respiratory distress. It is an urgent sign that the client's asthma is not
well-controlled and requires immediate medical intervention.
7. A nurse is caring for a client with acute renal failure. Which of the
following laboratory values should the nurse expect to be elevated?
diuretic. Which of the following laboratory results should the nurse
monitor?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum chloride
Answer: B) Serum potassium
Rationale: Diuretics, especially loop diuretics like furosemide, can cause
potassium depletion. Monitoring potassium levels is essential to
prevent hypokalemia, which can lead to life-threatening arrhythmias.
2. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is receiving supplemental oxygen. The nurse
notes the client’s oxygen saturation is 92%. Which of the following
actions should the nurse take?
A) Increase the oxygen flow rate.
B) Notify the healthcare provider.
C) Decrease the oxygen flow rate.
D) Assess for signs of hypercapnia.
Answer: C) Decrease the oxygen flow rate
Rationale: Clients with COPD are at risk for carbon dioxide retention,
and high levels of oxygen can further suppress respiratory drive.
Maintaining oxygen saturation within a safe range (88-92%) helps
prevent hypercapnia.
,3. A nurse is preparing to administer an antihypertensive medication
to a client with a blood pressure of 158/96 mmHg. Which of the
following actions should the nurse take before administering the
medication?
A) Assess for orthostatic hypotension
B) Check the client’s blood glucose levels
C) Assess for signs of hyperkalemia
D) Encourage the client to rest before medication administration
Answer: A) Assess for orthostatic hypotension
Rationale: Antihypertensive medications can cause orthostatic
hypotension (a sudden drop in blood pressure when standing). The
nurse should assess for this condition to reduce the risk of falls.
4. A nurse is caring for a postoperative client who is at risk for deep
vein thrombosis (DVT). Which of the following interventions should
the nurse include in the care plan?
A) Encourage the client to remain on bed rest
B) Apply elastic stockings to the client’s legs
C) Limit fluid intake to reduce edema
D) Encourage the client to remain immobile for 24 hours
Answer: B) Apply elastic stockings to the client’s legs
Rationale: Elastic stockings help prevent DVT by promoting venous
return and preventing stasis of blood in the lower extremities. Early
ambulation is also important to prevent DVT.
, 5. A nurse is caring for a client with a diagnosis of diabetes mellitus
who is experiencing hyperglycemia. The nurse should anticipate which
of the following interventions?
A) Administer insulin as prescribed
B) Encourage the client to drink fluids with high sugar content
C) Administer sodium bicarbonate to correct acidosis
D) Restrict the client’s fluid intake
Answer: A) Administer insulin as prescribed
Rationale: Hyperglycemia is managed with insulin therapy. The nurse
should follow the provider's orders for insulin to reduce blood glucose
levels and avoid complications such as diabetic ketoacidosis.
6. A nurse is caring for a client with an exacerbation of asthma. Which
of the following findings should the nurse report immediately to the
healthcare provider?
A) Decreased peak flow readings
B) Wheezing with exhalation
C) Use of accessory muscles for breathing
D) Oxygen saturation of 94%
Answer: C) Use of accessory muscles for breathing
Rationale: The use of accessory muscles for breathing indicates severe
respiratory distress. It is an urgent sign that the client's asthma is not
well-controlled and requires immediate medical intervention.
7. A nurse is caring for a client with acute renal failure. Which of the
following laboratory values should the nurse expect to be elevated?
