1. A nurse is caring for a client who has a history of seizures. Which of
the following interventions is most important to prevent injury during
a seizure? a) Restrain the client's arms and legs to prevent movement b)
Position the client in a prone position c) Place a padded tongue blade in
the client's mouth d) Position the client on their side to maintain an
open airway
Answer: d) Position the client on their side to maintain an open airway
Rationale: Positioning the client on their side helps prevent aspiration
and keeps the airway open during a seizure. Restraining the client or
placing objects in their mouth can cause harm.
2. A nurse is caring for a client who has been prescribed a proton pump
inhibitor (PPI) for gastroesophageal reflux disease (GERD). Which of
the following actions is most important for the nurse to monitor? a)
Heart rate b) Liver function c) Serum potassium levels d) Serum
calcium levels
Answer: b) Liver function
Rationale: PPIs can affect liver function, so it is important for the nurse
to monitor liver enzymes, particularly in clients who are on long-term
therapy.
3. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is using a bronchodilator. Which of the following
,side effects should the nurse monitor for? a) Bradycardia b) Weight
gain c) Tachycardia d) Hypotension
Answer: c) Tachycardia
Rationale: Bronchodilators, such as albuterol, can cause tachycardia as a
side effect. The nurse should monitor the client for this and other
cardiovascular symptoms.
4. Which of the following is the most important action for the nurse
when caring for a client who is receiving chemotherapy and has a low
white blood cell count? a) Encourage deep breathing exercises b)
Administer pain medications as prescribed c) Monitor for signs of
infection and maintain strict hand hygiene d) Provide frequent oral care
with antiseptic solutions
Answer: c) Monitor for signs of infection and maintain strict hand
hygiene
Rationale: A low white blood cell count (neutropenia) increases the risk
of infection. The nurse should closely monitor for infection and practice
strict hand hygiene to prevent the spread of pathogens.
5. A nurse is caring for a client with chronic heart failure. Which of the
following actions should the nurse take first to assess the client's
condition? a) Monitor the client's weight b) Auscultate the lungs for
crackles c) Check the client's blood pressure d) Assess the client's
peripheral pulses
Answer: b) Auscultate the lungs for crackles
, Rationale: Crackles are a common sign of fluid overload in heart failure.
Auscultating the lungs should be done first to assess for pulmonary
congestion.
6. A nurse is assessing a client who is receiving diuretic therapy. Which
of the following findings is the most concerning? a) Decreased blood
pressure b) Increased urination c) Hyperkalemia d) Weight loss
Answer: c) Hyperkalemia
Rationale: Hyperkalemia is a dangerous side effect of certain diuretics,
especially potassium-sparing diuretics. It can lead to life-threatening
arrhythmias and should be immediately addressed.
7. A nurse is caring for a client with an acute asthma attack. Which of
the following medications should the nurse administer first? a)
Intravenous corticosteroids b) Oral antibiotics c) Short-acting beta-
agonist (SABA) inhaler d) Long-acting beta-agonist (LABA) inhaler
Answer: c) Short-acting beta-agonist (SABA) inhaler
Rationale: A SABA, such as albuterol, is the first-line treatment for
acute asthma attacks. It helps to quickly open the airways and relieve
symptoms.
8. A nurse is caring for a client who has a prescription for a chest X-
ray. Which of the following is the most important question the nurse
should ask the client before the procedure? a) "Do you have a history of
asthma?" b) "Are you allergic to shellfish?" c) "Are you pregnant or is
the following interventions is most important to prevent injury during
a seizure? a) Restrain the client's arms and legs to prevent movement b)
Position the client in a prone position c) Place a padded tongue blade in
the client's mouth d) Position the client on their side to maintain an
open airway
Answer: d) Position the client on their side to maintain an open airway
Rationale: Positioning the client on their side helps prevent aspiration
and keeps the airway open during a seizure. Restraining the client or
placing objects in their mouth can cause harm.
2. A nurse is caring for a client who has been prescribed a proton pump
inhibitor (PPI) for gastroesophageal reflux disease (GERD). Which of
the following actions is most important for the nurse to monitor? a)
Heart rate b) Liver function c) Serum potassium levels d) Serum
calcium levels
Answer: b) Liver function
Rationale: PPIs can affect liver function, so it is important for the nurse
to monitor liver enzymes, particularly in clients who are on long-term
therapy.
3. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is using a bronchodilator. Which of the following
,side effects should the nurse monitor for? a) Bradycardia b) Weight
gain c) Tachycardia d) Hypotension
Answer: c) Tachycardia
Rationale: Bronchodilators, such as albuterol, can cause tachycardia as a
side effect. The nurse should monitor the client for this and other
cardiovascular symptoms.
4. Which of the following is the most important action for the nurse
when caring for a client who is receiving chemotherapy and has a low
white blood cell count? a) Encourage deep breathing exercises b)
Administer pain medications as prescribed c) Monitor for signs of
infection and maintain strict hand hygiene d) Provide frequent oral care
with antiseptic solutions
Answer: c) Monitor for signs of infection and maintain strict hand
hygiene
Rationale: A low white blood cell count (neutropenia) increases the risk
of infection. The nurse should closely monitor for infection and practice
strict hand hygiene to prevent the spread of pathogens.
5. A nurse is caring for a client with chronic heart failure. Which of the
following actions should the nurse take first to assess the client's
condition? a) Monitor the client's weight b) Auscultate the lungs for
crackles c) Check the client's blood pressure d) Assess the client's
peripheral pulses
Answer: b) Auscultate the lungs for crackles
, Rationale: Crackles are a common sign of fluid overload in heart failure.
Auscultating the lungs should be done first to assess for pulmonary
congestion.
6. A nurse is assessing a client who is receiving diuretic therapy. Which
of the following findings is the most concerning? a) Decreased blood
pressure b) Increased urination c) Hyperkalemia d) Weight loss
Answer: c) Hyperkalemia
Rationale: Hyperkalemia is a dangerous side effect of certain diuretics,
especially potassium-sparing diuretics. It can lead to life-threatening
arrhythmias and should be immediately addressed.
7. A nurse is caring for a client with an acute asthma attack. Which of
the following medications should the nurse administer first? a)
Intravenous corticosteroids b) Oral antibiotics c) Short-acting beta-
agonist (SABA) inhaler d) Long-acting beta-agonist (LABA) inhaler
Answer: c) Short-acting beta-agonist (SABA) inhaler
Rationale: A SABA, such as albuterol, is the first-line treatment for
acute asthma attacks. It helps to quickly open the airways and relieve
symptoms.
8. A nurse is caring for a client who has a prescription for a chest X-
ray. Which of the following is the most important question the nurse
should ask the client before the procedure? a) "Do you have a history of
asthma?" b) "Are you allergic to shellfish?" c) "Are you pregnant or is
