1. A nurse is caring for a client with a fever and a history of
tuberculosis (TB). Which of the following precautions should the nurse
take? a) Droplet precautions b) Airborne precautions c) Standard
precautions d) Contact precautions
Answer: b) Airborne precautions
Rationale: Tuberculosis is spread through airborne particles, and the
nurse should use airborne precautions to prevent transmission to
others.
2. A nurse is caring for a client with a urinary tract infection (UTI).
Which of the following interventions is most important? a) Administer
prescribed antibiotics b) Encourage the client to increase fluid intake c)
Apply a heating pad to the lower abdomen d) Instruct the client to
avoid caffeine
Answer: a) Administer prescribed antibiotics
Rationale: Antibiotics are the primary treatment for a UTI.
Administering them as prescribed is crucial to clear the infection and
prevent complications.
3. 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.
4. A nurse is caring for a client with cirrhosis of the liver. Which of the
following findings is most concerning? a) Jaundice b) Ascites c)
Decreased urine output d) Flatulence
Answer: c) Decreased urine output
Rationale: Decreased urine output may indicate acute kidney injury,
which is a serious complication of cirrhosis. This warrants immediate
assessment and intervention.
5. A nurse is caring for a client who is receiving IV fluids at a rate of
100 mL per hour. The nurse observes that the IV site is red and
swollen. Which of the following actions should the nurse take first? a)
Decrease the rate of infusion b) Discontinue the IV infusion c) Apply a
warm compress to the site d) Call the healthcare provider
Answer: b) Discontinue the IV infusion
Rationale: The red and swollen IV site indicates possible phlebitis or
infiltration. The first action is to discontinue the infusion to prevent
further complications.
, 6. A nurse is caring for a client with a fractured tibia. Which of the
following actions should the nurse take to promote healing? a)
Encourage the client to walk as much as possible b) Monitor for signs
of deep vein thrombosis (DVT) c) Apply heat to the injured leg d)
Perform passive range-of-motion exercises on the affected leg
Answer: b) Monitor for signs of deep vein thrombosis (DVT)
Rationale: Clients with fractures are at increased risk for DVT. The
nurse should monitor for symptoms such as swelling, pain, and redness
in the affected leg.
7. A nurse is providing discharge instructions to a client who has been
diagnosed with hypertension. Which of the following statements by the
client indicates the need for further teaching? a) "I will take my
medication at the same time every day." b) "I will reduce my salt intake
and exercise regularly." c) "I can stop my medication once my blood
pressure returns to normal." d) "I will monitor my blood pressure at
home as instructed."
Answer: c) "I can stop my medication once my blood pressure returns
to normal."
Rationale: Hypertension is a chronic condition that requires ongoing
management. The client should not stop their medication even if their
blood pressure appears normal, unless directed by the healthcare
provider.
8. A nurse is caring for a client who is receiving warfarin therapy.
Which of the following foods should the nurse advise the client to
tuberculosis (TB). Which of the following precautions should the nurse
take? a) Droplet precautions b) Airborne precautions c) Standard
precautions d) Contact precautions
Answer: b) Airborne precautions
Rationale: Tuberculosis is spread through airborne particles, and the
nurse should use airborne precautions to prevent transmission to
others.
2. A nurse is caring for a client with a urinary tract infection (UTI).
Which of the following interventions is most important? a) Administer
prescribed antibiotics b) Encourage the client to increase fluid intake c)
Apply a heating pad to the lower abdomen d) Instruct the client to
avoid caffeine
Answer: a) Administer prescribed antibiotics
Rationale: Antibiotics are the primary treatment for a UTI.
Administering them as prescribed is crucial to clear the infection and
prevent complications.
3. 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.
4. A nurse is caring for a client with cirrhosis of the liver. Which of the
following findings is most concerning? a) Jaundice b) Ascites c)
Decreased urine output d) Flatulence
Answer: c) Decreased urine output
Rationale: Decreased urine output may indicate acute kidney injury,
which is a serious complication of cirrhosis. This warrants immediate
assessment and intervention.
5. A nurse is caring for a client who is receiving IV fluids at a rate of
100 mL per hour. The nurse observes that the IV site is red and
swollen. Which of the following actions should the nurse take first? a)
Decrease the rate of infusion b) Discontinue the IV infusion c) Apply a
warm compress to the site d) Call the healthcare provider
Answer: b) Discontinue the IV infusion
Rationale: The red and swollen IV site indicates possible phlebitis or
infiltration. The first action is to discontinue the infusion to prevent
further complications.
, 6. A nurse is caring for a client with a fractured tibia. Which of the
following actions should the nurse take to promote healing? a)
Encourage the client to walk as much as possible b) Monitor for signs
of deep vein thrombosis (DVT) c) Apply heat to the injured leg d)
Perform passive range-of-motion exercises on the affected leg
Answer: b) Monitor for signs of deep vein thrombosis (DVT)
Rationale: Clients with fractures are at increased risk for DVT. The
nurse should monitor for symptoms such as swelling, pain, and redness
in the affected leg.
7. A nurse is providing discharge instructions to a client who has been
diagnosed with hypertension. Which of the following statements by the
client indicates the need for further teaching? a) "I will take my
medication at the same time every day." b) "I will reduce my salt intake
and exercise regularly." c) "I can stop my medication once my blood
pressure returns to normal." d) "I will monitor my blood pressure at
home as instructed."
Answer: c) "I can stop my medication once my blood pressure returns
to normal."
Rationale: Hypertension is a chronic condition that requires ongoing
management. The client should not stop their medication even if their
blood pressure appears normal, unless directed by the healthcare
provider.
8. A nurse is caring for a client who is receiving warfarin therapy.
Which of the following foods should the nurse advise the client to
