,1.
A nurse is caring for a client admitted with acute decompensated heart failure.
Which assessment finding requires immediate intervention?
A. Bilateral ankle edema graded as 2+
B. Weight gain of 1 kg over two days
C. Oxygen saturation of 84% on room air with severe dyspnea
D. Fatigue after walking to the bathroom
Answer: C
Severe hypoxemia with respiratory distress is life-threatening and requires
immediate oxygen therapy and further intervention.
2.
A client with type 1 diabetes becomes confused, diaphoretic, and shaky before
lunch. What is the nurse's priority action?
A. Administer long-acting insulin.
B. Obtain a urine specimen.
C. Encourage the client to walk.
D. Check the blood glucose level immediately.
Answer: D
,These findings suggest hypoglycemia. Confirming blood glucose allows prompt
treatment with fast-acting carbohydrates if indicated.
3.
Which assessment finding is most concerning in a client recovering from
abdominal surgery?
A. Pain rating of 5 out of 10
B. Hypoactive bowel sounds
C. Temperature of 38.9°C (102°F) with increasing incisional redness
D. Mild nausea after ambulation
Answer: C
Fever with worsening incision redness may indicate a postoperative infection
requiring prompt evaluation.
4.
A nurse is educating a client newly diagnosed with hypertension. Which lifestyle
modification should the nurse recommend first?
A. Increase sodium intake.
B. Eliminate all physical activity.
C. Follow a heart-healthy diet and exercise regularly.
, D. Drink more caffeinated beverages.
Answer: C
Lifestyle modifications such as the DASH diet, exercise, and weight management
are first-line strategies for blood pressure control.
5.
A client reports sudden crushing chest pain radiating to the left arm. Which
nursing action has the highest priority?
A. Document the pain score.
B. Encourage deep breathing.
C. Offer oral fluids.
D. Activate the chest pain protocol and obtain a 12-lead ECG.
Answer: D
Rapid recognition and treatment of acute coronary syndrome improve outcomes
and reduce myocardial damage.
6.
Which laboratory value requires immediate follow-up for a client receiving
warfarin therapy?
A. Hemoglobin 13.8 g/dL
A nurse is caring for a client admitted with acute decompensated heart failure.
Which assessment finding requires immediate intervention?
A. Bilateral ankle edema graded as 2+
B. Weight gain of 1 kg over two days
C. Oxygen saturation of 84% on room air with severe dyspnea
D. Fatigue after walking to the bathroom
Answer: C
Severe hypoxemia with respiratory distress is life-threatening and requires
immediate oxygen therapy and further intervention.
2.
A client with type 1 diabetes becomes confused, diaphoretic, and shaky before
lunch. What is the nurse's priority action?
A. Administer long-acting insulin.
B. Obtain a urine specimen.
C. Encourage the client to walk.
D. Check the blood glucose level immediately.
Answer: D
,These findings suggest hypoglycemia. Confirming blood glucose allows prompt
treatment with fast-acting carbohydrates if indicated.
3.
Which assessment finding is most concerning in a client recovering from
abdominal surgery?
A. Pain rating of 5 out of 10
B. Hypoactive bowel sounds
C. Temperature of 38.9°C (102°F) with increasing incisional redness
D. Mild nausea after ambulation
Answer: C
Fever with worsening incision redness may indicate a postoperative infection
requiring prompt evaluation.
4.
A nurse is educating a client newly diagnosed with hypertension. Which lifestyle
modification should the nurse recommend first?
A. Increase sodium intake.
B. Eliminate all physical activity.
C. Follow a heart-healthy diet and exercise regularly.
, D. Drink more caffeinated beverages.
Answer: C
Lifestyle modifications such as the DASH diet, exercise, and weight management
are first-line strategies for blood pressure control.
5.
A client reports sudden crushing chest pain radiating to the left arm. Which
nursing action has the highest priority?
A. Document the pain score.
B. Encourage deep breathing.
C. Offer oral fluids.
D. Activate the chest pain protocol and obtain a 12-lead ECG.
Answer: D
Rapid recognition and treatment of acute coronary syndrome improve outcomes
and reduce myocardial damage.
6.
Which laboratory value requires immediate follow-up for a client receiving
warfarin therapy?
A. Hemoglobin 13.8 g/dL
