1. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). Which of the following interventions is most
important when providing care to this client? a) Provide supplemental
oxygen to maintain oxygen saturation above 95% b) Encourage the
client to cough forcefully to clear secretions c) Monitor for signs of
respiratory distress and administer bronchodilators as needed d) Keep
the client in a supine position to promote lung expansion
Answer: c) Monitor for signs of respiratory distress and administer
bronchodilators as needed
Rationale: Monitoring for respiratory distress and administering
bronchodilators helps to manage COPD symptoms and prevent
exacerbations. Oxygen should be administered cautiously to avoid
carbon dioxide retention.
2. 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.
3. A nurse is caring for a client with chronic kidney disease (CKD).
Which of the following lab results is most concerning? a) Elevated
,blood urea nitrogen (BUN) b) Elevated serum creatinine level c)
Decreased hemoglobin level d) Increased potassium level
Answer: d) Increased potassium level
Rationale: Elevated potassium levels are a critical concern in CKD, as
hyperkalemia can lead to life-threatening arrhythmias. The nurse
should prioritize monitoring and managing potassium levels in these
clients.
4. 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.
5. A client who has undergone a colonoscopy is ready for discharge.
Which of the following instructions should the nurse include in the
discharge teaching? a) "You can resume normal activities immediately."
b) "You should refrain from eating for the next 12 hours." c) "You may
experience mild cramping or bloating for a few hours." d) "Take a
laxative if you experience constipation within 24 hours."
Answer: c) "You may experience mild cramping or bloating for a few
hours."
, Rationale: Mild cramping or bloating is a common side effect after a
colonoscopy due to air introduced into the colon during the procedure.
The nurse should educate the client on this and reassure them that it
should resolve on its own.
6. 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.
7. 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.
disease (COPD). Which of the following interventions is most
important when providing care to this client? a) Provide supplemental
oxygen to maintain oxygen saturation above 95% b) Encourage the
client to cough forcefully to clear secretions c) Monitor for signs of
respiratory distress and administer bronchodilators as needed d) Keep
the client in a supine position to promote lung expansion
Answer: c) Monitor for signs of respiratory distress and administer
bronchodilators as needed
Rationale: Monitoring for respiratory distress and administering
bronchodilators helps to manage COPD symptoms and prevent
exacerbations. Oxygen should be administered cautiously to avoid
carbon dioxide retention.
2. 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.
3. A nurse is caring for a client with chronic kidney disease (CKD).
Which of the following lab results is most concerning? a) Elevated
,blood urea nitrogen (BUN) b) Elevated serum creatinine level c)
Decreased hemoglobin level d) Increased potassium level
Answer: d) Increased potassium level
Rationale: Elevated potassium levels are a critical concern in CKD, as
hyperkalemia can lead to life-threatening arrhythmias. The nurse
should prioritize monitoring and managing potassium levels in these
clients.
4. 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.
5. A client who has undergone a colonoscopy is ready for discharge.
Which of the following instructions should the nurse include in the
discharge teaching? a) "You can resume normal activities immediately."
b) "You should refrain from eating for the next 12 hours." c) "You may
experience mild cramping or bloating for a few hours." d) "Take a
laxative if you experience constipation within 24 hours."
Answer: c) "You may experience mild cramping or bloating for a few
hours."
, Rationale: Mild cramping or bloating is a common side effect after a
colonoscopy due to air introduced into the colon during the procedure.
The nurse should educate the client on this and reassure them that it
should resolve on its own.
6. 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.
7. 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.
