Answers | Latest Version | 2025/2026 |
Correct & Verified
A nurse is caring for a client with pneumonia who has a productive cough and fever. Which of
the following is the priority action?
A. Encourage fluid intake
✔✔ B. Apply oxygen via nasal cannula
C. Administer antipyretics
D. Obtain sputum culture
A nurse is assessing a client with a new diagnosis of heart failure. Which of the following
findings should the nurse report immediately?
A. 2+ pitting edema
B. Weight gain of 2 lbs in 2 days
✔✔ C. Pink, frothy sputum
D. Fatigue and weakness
A nurse is reinforcing teaching with a client who has a new prescription for furosemide. Which
of the following instructions should the nurse include?
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,✔✔ A. Rise slowly when getting out of bed
B. Limit potassium-rich foods
C. Take before bedtime
D. Avoid all dairy products
A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the following
actions should the nurse take before the procedure?
A. Check bowel sounds
✔✔ B. Verify informed consent
C. Encourage deep breathing
D. Apply antiembolism stockings
A nurse is monitoring a client with a chest tube in place. Which of the following findings should
be reported to the provider?
A. Gentle bubbling in the suction chamber
✔✔ B. Continuous bubbling in the water seal chamber
C. Drainage of 40 mL/hr
D. Fluctuation of fluid with respiration
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,A nurse is teaching a client with type 2 diabetes about foot care. Which of the following client
statements indicates understanding?
A. “I will soak my feet every night before bed.”
B. “I will cut my toenails very short to avoid problems.”
✔✔ C. “I will wear cotton socks and well-fitting shoes.”
D. “I will apply lotion between my toes daily.”
A nurse is caring for a client who just returned from abdominal surgery. Which of the following
findings is most important to report?
A. Hypoactive bowel sounds
✔✔ B. Absent urine output in 2 hours
C. Pain level of 5 on 0-10 scale
D. Small amount of serosanguinous drainage
A nurse is caring for a client who has been receiving opioid pain medication for several days.
Which of the following is an expected side effect?
A. Diarrhea
✔✔ B. Constipation
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, C. Polyuria
D. Tachycardia
A nurse is assessing a client with left-sided stroke. Which of the following findings is expected?
✔✔ A. Right-sided weakness
B. Difficulty breathing
C. Vision loss in both eyes
D. Flaccid muscles on the left
A nurse is caring for a client who has a new tracheostomy. Which of the following actions should
the nurse take when performing tracheostomy care?
A. Clean the inner cannula with sterile alcohol
✔✔ B. Use sterile gloves when performing care
C. Suction for 20 seconds continuously
D. Replace the ties every shift without checking fit
A nurse is reinforcing discharge teaching with a client who had a total hip replacement. Which of
the following statements indicates understanding?
A. “I will bend at the waist to pick things up.”
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