1. A nurse is caring for a client who is receiving chemotherapy.
Which of the
following actions should the nurse take to reduce the risk of
infection?
A. Provide the client with a high-protein diet.
B. Place the client in a private room.
C. Offer fresh fruits and vegetables to the client.
D. Limit the client’s fluid intake to prevent fluid overload.
Answer: b) Place the client in a private room.
Rationale: Chemotherapy suppresses the immune system,
increasing the risk of infection.
Placing the client in a private room reduces exposure to
potential sources of infection.
2. A nurse is caring for a client who is receiving chemotherapy.
Which of the
following is the priority assessment?
A. White blood cell count.
B. Blood pressure.
C. Respiratory rate.
D. Weight.
Answer: a) White blood cell count.
,Rationale: Chemotherapy can suppress bone marrow function,
leading to a decrease in white
blood cell count and increasing the risk for infection. Monitoring
white blood cell count is a
priority.
3. A nurse is caring for a client with a history of heart failure who
is receiving
digoxin. Which of the following findings should the nurse report
to the provider?
A. Apical pulse of 72 bpm
B. Serum potassium level of 3.2 mEq/L
C. Blood pressure of 110/70 mmHg
D. Respiratory rate of 18 breaths per minute
Answer: b) Serum potassium level of 3.2 mEq/L
Rationale: Low potassium levels increase the risk of digoxin
toxicity. The nurse should report a
potassium level of 3.2 mEq/L, which is below the normal range of
3.5-5.0 mEq/L.
4. A nurse is caring for a client with a history of peptic ulcer
disease. Which of
the following should the nurse include in the teaching?
A. "You can take over-the-counter antacids for pain relief."
,B. "You should avoid eating large meals."
C. "You should avoid caffeine and alcohol."
D. "You can continue smoking to relieve stress."
Answer: c) "You should avoid caffeine and alcohol."
Rationale: Caffeine and alcohol can irritate the stomach lining
and worsen symptoms of peptic
ulcer disease.
5. A nurse is caring for a client with a urinary tract infection
(UTI). Which of
the following statements by the client indicates a need for
further teaching?
A. "I should drink plenty of fluids."
B. "I will take my antibiotics until I feel better."
C. "I should wipe from front to back after using the toilet."
D. "I will urinate when I feel the urge, even if it’s inconvenient."
Answer: b) "I will take my antibiotics until I feel better."
Rationale: The client should be instructed to complete the full
course of antibiotics, even if they
feel better, to prevent antibiotic resistance and recurrence of the
infection.
6. A nurse is caring for a client with a diagnosis of
hyperthyroidism. Which of
, the following findings should the nurse report to the provider
immediately?
A. Increased appetite
B. Restlessness and irritability
C. Temperature of 100.4°F (38°C)
D. Increased blood pressure
Answer: c) Temperature of 100.4°F (38°C)
Rationale: A temperature of 100.4°F could indicate thyroid storm,
a life-threatening condition
that requires immediate intervention in clients with
hyperthyroidism.
7. A nurse is caring for a client with chronic obstructive
pulmonary disease
(COPD). The client is using a home oxygen therapy system at 2
L/min. Which of
the following should the nurse include in the teaching?
A. "You should limit your fluid intake to reduce secretions."
B. "You can increase the oxygen flow rate during physical
activity."
C. "You should wear a mask when using your oxygen therapy
system."
D. "You should avoid smoking while using oxygen therapy."
Answer: d) "You should avoid smoking while using oxygen
therapy."
Which of the
following actions should the nurse take to reduce the risk of
infection?
A. Provide the client with a high-protein diet.
B. Place the client in a private room.
C. Offer fresh fruits and vegetables to the client.
D. Limit the client’s fluid intake to prevent fluid overload.
Answer: b) Place the client in a private room.
Rationale: Chemotherapy suppresses the immune system,
increasing the risk of infection.
Placing the client in a private room reduces exposure to
potential sources of infection.
2. A nurse is caring for a client who is receiving chemotherapy.
Which of the
following is the priority assessment?
A. White blood cell count.
B. Blood pressure.
C. Respiratory rate.
D. Weight.
Answer: a) White blood cell count.
,Rationale: Chemotherapy can suppress bone marrow function,
leading to a decrease in white
blood cell count and increasing the risk for infection. Monitoring
white blood cell count is a
priority.
3. A nurse is caring for a client with a history of heart failure who
is receiving
digoxin. Which of the following findings should the nurse report
to the provider?
A. Apical pulse of 72 bpm
B. Serum potassium level of 3.2 mEq/L
C. Blood pressure of 110/70 mmHg
D. Respiratory rate of 18 breaths per minute
Answer: b) Serum potassium level of 3.2 mEq/L
Rationale: Low potassium levels increase the risk of digoxin
toxicity. The nurse should report a
potassium level of 3.2 mEq/L, which is below the normal range of
3.5-5.0 mEq/L.
4. A nurse is caring for a client with a history of peptic ulcer
disease. Which of
the following should the nurse include in the teaching?
A. "You can take over-the-counter antacids for pain relief."
,B. "You should avoid eating large meals."
C. "You should avoid caffeine and alcohol."
D. "You can continue smoking to relieve stress."
Answer: c) "You should avoid caffeine and alcohol."
Rationale: Caffeine and alcohol can irritate the stomach lining
and worsen symptoms of peptic
ulcer disease.
5. A nurse is caring for a client with a urinary tract infection
(UTI). Which of
the following statements by the client indicates a need for
further teaching?
A. "I should drink plenty of fluids."
B. "I will take my antibiotics until I feel better."
C. "I should wipe from front to back after using the toilet."
D. "I will urinate when I feel the urge, even if it’s inconvenient."
Answer: b) "I will take my antibiotics until I feel better."
Rationale: The client should be instructed to complete the full
course of antibiotics, even if they
feel better, to prevent antibiotic resistance and recurrence of the
infection.
6. A nurse is caring for a client with a diagnosis of
hyperthyroidism. Which of
, the following findings should the nurse report to the provider
immediately?
A. Increased appetite
B. Restlessness and irritability
C. Temperature of 100.4°F (38°C)
D. Increased blood pressure
Answer: c) Temperature of 100.4°F (38°C)
Rationale: A temperature of 100.4°F could indicate thyroid storm,
a life-threatening condition
that requires immediate intervention in clients with
hyperthyroidism.
7. A nurse is caring for a client with chronic obstructive
pulmonary disease
(COPD). The client is using a home oxygen therapy system at 2
L/min. Which of
the following should the nurse include in the teaching?
A. "You should limit your fluid intake to reduce secretions."
B. "You can increase the oxygen flow rate during physical
activity."
C. "You should wear a mask when using your oxygen therapy
system."
D. "You should avoid smoking while using oxygen therapy."
Answer: d) "You should avoid smoking while using oxygen
therapy."
