and Answers | Latest Version | 2025/2026
| Correct & Verified
A client with diabetes is shaky, sweaty, and confused. What is the nurse’s first action?
A. Call the provider
✔✔B. Give 15 g of fast-acting carbohydrate
C. Start IV insulin
D. Administer glucagon
A client is receiving IV vancomycin. Which finding requires immediate intervention?
A. Mild fatigue
✔✔B. Red rash on face and chest
C. Mild nausea
D. Increased thirst
A client with pneumonia is producing thick secretions. Which nursing action is best?
A. Limit oral fluids
B. Suction once per shift
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,✔✔C. Encourage oral fluid intake
D. Place in Trendelenburg
A nurse is teaching a client taking warfarin. Which food should be avoided?
A. Apples
B. Rice
✔✔C. Spinach
D. Chicken
A client post-thyroidectomy reports tingling around lips and fingers. Which lab should the nurse
check first?
A. Potassium
✔✔B. Calcium
C. Sodium
D. Hemoglobin
A client receiving morphine IV is difficult to arouse and has a respiratory rate of 6/min. What is
the nurse’s priority?
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,✔✔A. Administer naloxone
B. Provide emotional support
C. Increase IV fluids
D. Document the finding
A client with heart failure reports sudden weight gain of 3 lbs in 24 hours. What is the nurse’s
first action?
✔✔A. Notify the healthcare provider
B. Encourage fluids
C. Reassure client this is expected
D. Apply warm compress
A client with burns covering 30% of the body surface is at highest risk in the first 24 hours for
which complication?
A. Sepsis
B. Contractures
✔✔C. Hypovolemic shock
D. Pulmonary embolism
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, A client receiving chemotherapy develops white patches in the mouth. What does the nurse
suspect?
A. Dehydration
✔✔B. Oral candidiasis
C. Vitamin deficiency
D. Dental infection
A client is receiving TPN. Which finding requires immediate action?
A. Weight gain of 1 lb in 3 days
✔✔B. Sudden shortness of breath and chest pain
C. Mild increase in appetite
D. Elevated blood glucose
A client with schizophrenia states, “The voices are telling me to hurt myself.” What is the nurse’s
priority?
✔✔A. Assess safety and implement suicide precautions
B. Offer medication education
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