1. A nurse is caring for a client with hypertension. Which of the
following actions should the nurse implement to prevent
complications of hypertension?
A. Encourage the client to limit sodium intake.
B. Recommend the client avoid alcohol consumption.
C. Advise the client to maintain a low-fat diet.
D. Suggest the client increase potassium intake.
Answer: A. Encourage the client to limit sodium intake.
Rationale: Reducing sodium intake helps lower blood pressure by
decreasing fluid retention. Limiting sodium is a key intervention in
managing hypertension to prevent complications like heart failure and
stroke. Although avoiding alcohol, maintaining a healthy diet, and
increasing potassium are important, the primary action to manage
hypertension is sodium reduction.
2. The nurse is assessing a client with diabetes mellitus who has
developed diabetic neuropathy. Which of the following findings is
most indicative of diabetic neuropathy?
A. Bilateral foot numbness.
B. Decreased peripheral pulses.
C. Pitting edema of the legs.
D. Painful ulcers on the lower legs.
Answer: A. Bilateral foot numbness.
Rationale: Diabetic neuropathy often causes sensory changes, including
numbness, tingling, or pain, most commonly in the feet. This is due to
nerve damage from prolonged high blood sugar levels. Decreased
,pulses, edema, and ulcers may be related to vascular or other
complications, but numbness is characteristic of neuropathy.
3. A nurse is providing care to a client with acute pancreatitis. Which
of the following is the priority nursing intervention?
A. Administer pain medications.
B. Monitor vital signs.
C. Encourage oral hydration.
D. Place the client in a low Fowler’s position.
Answer: B. Monitor vital signs.
Rationale: Acute pancreatitis can lead to life-threatening complications
such as shock, respiratory distress, or organ failure. Monitoring vital
signs is a priority to assess for signs of these complications. While pain
management is important, the immediate priority is to assess for any
vital sign changes that could indicate worsening of the condition.
4. A nurse is assessing a client who has just undergone a below-the-
knee amputation. Which of the following findings is the nurse’s
priority?
A. The stump is red and swollen.
B. The client’s pain level is 5/10.
C. The client’s family asks how to help with rehabilitation.
D. The client is having difficulty breathing.
Answer: D. The client is having difficulty breathing.
Rationale: Difficulty breathing could indicate a serious complication
such as a pulmonary embolism or other respiratory issue, which
, requires immediate attention. The other options are important but not
as time-sensitive as respiratory distress.
5. The nurse is preparing to administer a blood transfusion to a client.
Which action should the nurse take first?
A. Check the client’s vital signs.
B. Verify the client’s blood type with another nurse.
C. Obtain a written consent for the procedure.
D. Administer a pre-transfusion medication to prevent allergic reactions.
Answer: B. Verify the client’s blood type with another nurse.
Rationale: Ensuring the blood is compatible with the client’s blood type
is the most critical step before administering a blood transfusion. This
helps prevent a life-threatening hemolytic reaction. Vital signs, consent,
and medications are important but secondary to confirming
compatibility.
6. A nurse is teaching a client about managing chronic obstructive
pulmonary disease (COPD). Which of the following instructions should
the nurse include?
A. "Use your inhalers only when you experience shortness of breath."
B. "Increase fluid intake to thin secretions."
C. "Avoid regular exercise, as it may worsen your condition."
D. "You should limit all physical activity to avoid fatigue."
Answer: B. "Increase fluid intake to thin secretions."
Rationale: Increasing fluid intake helps to thin mucus secretions, which
can ease breathing. Clients with COPD should engage in regular,
following actions should the nurse implement to prevent
complications of hypertension?
A. Encourage the client to limit sodium intake.
B. Recommend the client avoid alcohol consumption.
C. Advise the client to maintain a low-fat diet.
D. Suggest the client increase potassium intake.
Answer: A. Encourage the client to limit sodium intake.
Rationale: Reducing sodium intake helps lower blood pressure by
decreasing fluid retention. Limiting sodium is a key intervention in
managing hypertension to prevent complications like heart failure and
stroke. Although avoiding alcohol, maintaining a healthy diet, and
increasing potassium are important, the primary action to manage
hypertension is sodium reduction.
2. The nurse is assessing a client with diabetes mellitus who has
developed diabetic neuropathy. Which of the following findings is
most indicative of diabetic neuropathy?
A. Bilateral foot numbness.
B. Decreased peripheral pulses.
C. Pitting edema of the legs.
D. Painful ulcers on the lower legs.
Answer: A. Bilateral foot numbness.
Rationale: Diabetic neuropathy often causes sensory changes, including
numbness, tingling, or pain, most commonly in the feet. This is due to
nerve damage from prolonged high blood sugar levels. Decreased
,pulses, edema, and ulcers may be related to vascular or other
complications, but numbness is characteristic of neuropathy.
3. A nurse is providing care to a client with acute pancreatitis. Which
of the following is the priority nursing intervention?
A. Administer pain medications.
B. Monitor vital signs.
C. Encourage oral hydration.
D. Place the client in a low Fowler’s position.
Answer: B. Monitor vital signs.
Rationale: Acute pancreatitis can lead to life-threatening complications
such as shock, respiratory distress, or organ failure. Monitoring vital
signs is a priority to assess for signs of these complications. While pain
management is important, the immediate priority is to assess for any
vital sign changes that could indicate worsening of the condition.
4. A nurse is assessing a client who has just undergone a below-the-
knee amputation. Which of the following findings is the nurse’s
priority?
A. The stump is red and swollen.
B. The client’s pain level is 5/10.
C. The client’s family asks how to help with rehabilitation.
D. The client is having difficulty breathing.
Answer: D. The client is having difficulty breathing.
Rationale: Difficulty breathing could indicate a serious complication
such as a pulmonary embolism or other respiratory issue, which
, requires immediate attention. The other options are important but not
as time-sensitive as respiratory distress.
5. The nurse is preparing to administer a blood transfusion to a client.
Which action should the nurse take first?
A. Check the client’s vital signs.
B. Verify the client’s blood type with another nurse.
C. Obtain a written consent for the procedure.
D. Administer a pre-transfusion medication to prevent allergic reactions.
Answer: B. Verify the client’s blood type with another nurse.
Rationale: Ensuring the blood is compatible with the client’s blood type
is the most critical step before administering a blood transfusion. This
helps prevent a life-threatening hemolytic reaction. Vital signs, consent,
and medications are important but secondary to confirming
compatibility.
6. A nurse is teaching a client about managing chronic obstructive
pulmonary disease (COPD). Which of the following instructions should
the nurse include?
A. "Use your inhalers only when you experience shortness of breath."
B. "Increase fluid intake to thin secretions."
C. "Avoid regular exercise, as it may worsen your condition."
D. "You should limit all physical activity to avoid fatigue."
Answer: B. "Increase fluid intake to thin secretions."
Rationale: Increasing fluid intake helps to thin mucus secretions, which
can ease breathing. Clients with COPD should engage in regular,
