Answers | Latest Version | 2025/2026 |
Correct & Verified
A client with diabetes reports dizziness and sweating after breakfast. What should the nurse do
first?
a. Encourage the client to rest
b. Administer scheduled insulin
✔✔c. Check the client’s blood glucose immediately
d. Notify the healthcare provider
**Rationale:** Hypoglycemia is life-threatening; blood glucose assessment guides urgent care.
A client with COPD reports increased wheezing and O₂ saturation of 82%. What is the priority
intervention?
a. Encourage deep breathing exercises
b. Administer scheduled medications
✔✔c. Administer supplemental oxygen and assess respiratory status
d. Document the findings
**Rationale:** Hypoxemia requires immediate action.
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,A nurse notes that a client’s surgical dressing is saturated with bright red blood. What is the first
action?
a. Change the dressing
✔✔b. Assess the wound for active bleeding and vital signs
c. Notify family
d. Document the findings
**Rationale:** Active bleeding is an emergency; assessment guides immediate intervention.
A client receiving IV potassium reports burning at the site. What should the nurse do first?
✔✔a. Stop the infusion and assess for infiltration
b. Slow the infusion
c. Notify the provider later
d. Document the finding
**Rationale:** IV potassium infiltration can cause tissue damage; assessment is priority.
A client with a tracheostomy develops sudden stridor. What should the nurse do first?
a. Suction the tracheostomy
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, ✔✔b. Assess airway patency and oxygenation
c. Notify provider
d. Document the event
**Rationale:** Stridor indicates airway obstruction; immediate assessment is necessary.
A client on a PCA pump has a respiratory rate of 8/min. What is the nurse’s priority action?
a. Administer additional pain medication
✔✔b. Stop the opioid and assess respiratory status
c. Encourage deep breathing
d. Document the finding
**Rationale:** Respiratory depression is life-threatening and takes priority over pain.
A client reports sudden weakness on one side of the body and slurred speech. What should the
nurse do first?
✔✔a. Perform a focused neurological assessment and vital signs
b. Notify family
c. Document the findings
d. Reposition the client
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