Questions and Answers | Latest
Version | 2025/2026 | Correct & Verified
A client is admitted with severe dehydration and confusion. What is the priority nursing action?
✔✔Initiate IV access and begin fluid replacement.
A nurse walks into a room and finds a client having a seizure. What is the first action?
✔✔Lower the client to the floor and protect their head.
A client is receiving chemotherapy and reports a sore throat and chills. What should the nurse do
next?
✔✔Check the client’s temperature and notify the provider.
A nurse is reinforcing education about insulin injection sites. What should the nurse tell the
client?
✔✔Rotate injection sites within the same anatomical area to prevent lipodystrophy.
A client is receiving digoxin and reports nausea and blurred vision. What is the nurse’s priority?
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,✔✔Withhold the medication and check the apical pulse.
A nurse is reviewing discharge instructions for a client with a new colostomy. What is important
to teach?
✔✔Empty the pouch when it is one-third to half full.
A nurse is caring for a client receiving blood transfusion therapy. What is the first sign of a
transfusion reaction?
✔✔Chills and low back pain.
A nurse enters the room of a client receiving oxygen by nasal cannula and smells smoke. What is
the priority action?
✔✔Remove the oxygen and move the client away from the fire risk.
A client with chronic obstructive pulmonary disease is receiving oxygen at 4 L/min. What should
concern the nurse?
✔✔High oxygen flow may suppress the client’s respiratory drive.
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,A client is preparing for discharge after a myocardial infarction. What lifestyle advice is
essential?
✔✔Engage in moderate physical activity as tolerated and quit smoking.
A nurse is caring for a postpartum client who is Rh-negative and gave birth to an Rh-positive
infant. What is the appropriate intervention?
✔✔Administer Rho(D) immune globulin within 72 hours.
A client with a hip fracture is placed in Buck’s traction. What is a key nursing responsibility?
✔✔Ensure the weights hang freely and do not touch the floor.
A nurse is caring for a client on contact precautions. What is the correct PPE?
✔✔Gown and gloves before entering the room.
A nurse is preparing to administer ear drops to an adult client. What technique should be used?
✔✔Pull the auricle up and back before administering.
A client is being discharged on warfarin. What food should the nurse advise the client to limit?
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, ✔✔Leafy green vegetables due to high vitamin K content.
A nurse is teaching a client with asthma about the use of a peak flow meter. What is the correct
technique?
✔✔Take a deep breath, blow hard and fast into the meter, and record the highest reading.
A client with a history of heart failure has gained 2 kg in 2 days. What is the nurse’s next action?
✔✔Notify the provider as this indicates fluid retention.
A nurse is reinforcing discharge teaching to a client with newly diagnosed hypertension. What
should be emphasized?
✔✔Check blood pressure daily and limit sodium intake.
A nurse finds a post-op client with a saturated abdominal dressing. What is the priority action?
✔✔Apply pressure, reinforce the dressing, and notify the provider.
A client is confused and repeatedly trying to get out of bed. What is the best nursing
intervention?
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