1. Which of the following is the priority intervention for a client
experiencing a myocardial infarction (MI)?
A) Administering pain medication
B) Administering aspirin
C) Preparing the client for an angioplasty
D) Administering oxygen
Answer: D) Administering oxygen
Rationale: The priority intervention for a client experiencing a
myocardial infarction (MI) is to ensure adequate oxygenation to prevent
further damage to the heart. Oxygen helps to maintain oxygen
saturation levels and prevent ischemia. While aspirin and pain
medications are also important, oxygen is the immediate priority.
2. A nurse is caring for a client with diabetes mellitus who is newly
diagnosed with peripheral neuropathy. Which of the following
interventions is most important to include in the plan of care?
A) Encourage the client to avoid weight-bearing exercises
B) Teach the client to check their feet daily for signs of injury
C) Advise the client to wear cotton socks for comfort
D) Ensure the client wears shoes with an open toe design
Answer: B) Teach the client to check their feet daily for signs of injury
Rationale: Peripheral neuropathy can lead to reduced sensation in the
feet, increasing the risk for undetected injuries and infections. Teaching
the client to inspect their feet daily for cuts, blisters, or redness is
essential to prevent complications.
,3. Which of the following is the most appropriate nursing intervention
for a client with chronic obstructive pulmonary disease (COPD) during
an exacerbation?
A) Administer high-flow oxygen
B) Encourage deep coughing and coughing up secretions
C) Position the client in a high-Fowler's position
D) Administer sedative medication for anxiety
Answer: C) Position the client in a high-Fowler's position
Rationale: A high-Fowler’s position (sitting upright) helps to maximize
lung expansion and promotes better airflow in clients with COPD during
an exacerbation. This position facilitates easier breathing and
oxygenation.
4. A nurse is caring for a client with cirrhosis who develops ascites.
Which of the following interventions should the nurse implement
first?
A) Administer diuretics as prescribed
B) Monitor the client's weight daily
C) Restrict the client's sodium intake
D) Prepare the client for paracentesis
Answer: D) Prepare the client for paracentesis
Rationale: Paracentesis is typically the first intervention in clients with
ascites to remove excess fluid. Following the procedure, other
interventions like sodium restriction, diuretics, and daily weight
monitoring can be implemented to manage the condition.
, 5. A client with a history of alcohol use disorder is admitted with a
diagnosis of delirium tremens. Which of the following findings is most
concerning to the nurse?
A) Increased heart rate
B) Hyperreflexia
C) Nausea and vomiting
D) Hypotension
Answer: D) Hypotension
Rationale: Hypotension in a client with delirium tremens is concerning
because it can indicate shock or cardiovascular collapse, which are life-
threatening complications. Delirium tremens is often associated with
autonomic instability, but hypotension can be a sign of severe
dehydration or cardiovascular compromise.
6. Which of the following is the most common cause of community-
acquired pneumonia in adults?
A) Staphylococcus aureus
B) Pseudomonas aeruginosa
C) Streptococcus pneumoniae
D) Mycoplasma pneumoniae
Answer: C) Streptococcus pneumoniae
Rationale: Streptococcus pneumoniae is the most common causative
organism for community-acquired pneumonia in adults. It is important
to initiate appropriate antibiotics based on the suspected pathogen to
prevent complications.
experiencing a myocardial infarction (MI)?
A) Administering pain medication
B) Administering aspirin
C) Preparing the client for an angioplasty
D) Administering oxygen
Answer: D) Administering oxygen
Rationale: The priority intervention for a client experiencing a
myocardial infarction (MI) is to ensure adequate oxygenation to prevent
further damage to the heart. Oxygen helps to maintain oxygen
saturation levels and prevent ischemia. While aspirin and pain
medications are also important, oxygen is the immediate priority.
2. A nurse is caring for a client with diabetes mellitus who is newly
diagnosed with peripheral neuropathy. Which of the following
interventions is most important to include in the plan of care?
A) Encourage the client to avoid weight-bearing exercises
B) Teach the client to check their feet daily for signs of injury
C) Advise the client to wear cotton socks for comfort
D) Ensure the client wears shoes with an open toe design
Answer: B) Teach the client to check their feet daily for signs of injury
Rationale: Peripheral neuropathy can lead to reduced sensation in the
feet, increasing the risk for undetected injuries and infections. Teaching
the client to inspect their feet daily for cuts, blisters, or redness is
essential to prevent complications.
,3. Which of the following is the most appropriate nursing intervention
for a client with chronic obstructive pulmonary disease (COPD) during
an exacerbation?
A) Administer high-flow oxygen
B) Encourage deep coughing and coughing up secretions
C) Position the client in a high-Fowler's position
D) Administer sedative medication for anxiety
Answer: C) Position the client in a high-Fowler's position
Rationale: A high-Fowler’s position (sitting upright) helps to maximize
lung expansion and promotes better airflow in clients with COPD during
an exacerbation. This position facilitates easier breathing and
oxygenation.
4. A nurse is caring for a client with cirrhosis who develops ascites.
Which of the following interventions should the nurse implement
first?
A) Administer diuretics as prescribed
B) Monitor the client's weight daily
C) Restrict the client's sodium intake
D) Prepare the client for paracentesis
Answer: D) Prepare the client for paracentesis
Rationale: Paracentesis is typically the first intervention in clients with
ascites to remove excess fluid. Following the procedure, other
interventions like sodium restriction, diuretics, and daily weight
monitoring can be implemented to manage the condition.
, 5. A client with a history of alcohol use disorder is admitted with a
diagnosis of delirium tremens. Which of the following findings is most
concerning to the nurse?
A) Increased heart rate
B) Hyperreflexia
C) Nausea and vomiting
D) Hypotension
Answer: D) Hypotension
Rationale: Hypotension in a client with delirium tremens is concerning
because it can indicate shock or cardiovascular collapse, which are life-
threatening complications. Delirium tremens is often associated with
autonomic instability, but hypotension can be a sign of severe
dehydration or cardiovascular compromise.
6. Which of the following is the most common cause of community-
acquired pneumonia in adults?
A) Staphylococcus aureus
B) Pseudomonas aeruginosa
C) Streptococcus pneumoniae
D) Mycoplasma pneumoniae
Answer: C) Streptococcus pneumoniae
Rationale: Streptococcus pneumoniae is the most common causative
organism for community-acquired pneumonia in adults. It is important
to initiate appropriate antibiotics based on the suspected pathogen to
prevent complications.
