Latest Version | 2025/2026 | Correct &
Verified
What is the first nursing action when a client reports shortness of breath while lying flat?
✔✔Assist the client into a high-Fowler's position to promote lung expansion and ease breathing.
How should a nurse confirm the placement of a nasogastric tube before administering
medication?
✔✔Verify placement with an X-ray before the initial use and assess pH of aspirate before each
use.
What is a key indication of fluid volume overload in a client with heart failure?
✔✔Presence of crackles in the lungs and weight gain over a short period.
How can a nurse reduce the risk of falls in an older adult with unsteady gait?
✔✔Apply nonskid footwear, keep the call light within reach, and use bed alarms if needed.
What is the priority action if a client receiving IV potassium chloride reports burning at the site?
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, ✔✔Stop the infusion, assess the site for infiltration or phlebitis, and notify the provider.
What is the appropriate needle size for administering a subcutaneous heparin injection?
✔✔Use a 25- to 27-gauge, 3/8- to 5/8-inch needle at a 45- or 90-degree angle.
What lab value should be monitored closely in a client taking warfarin?
✔✔INR (International Normalized Ratio) to assess bleeding risk and effectiveness of therapy.
What is a priority nursing intervention for a client with schizophrenia experiencing command
hallucinations?
✔✔Ensure client safety and redirect their attention away from the hallucinations.
What is a common side effect of furosemide that the nurse should monitor for?
✔✔Hypokalemia, which can cause muscle weakness and cardiac arrhythmias.
What is an early sign of hypoglycemia a nurse should recognize?
✔✔Shakiness, irritability, and sweating are early signs of low blood glucose.
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