and Answers | Latest Version | 2025/2026
| Correct & Verified
A client who had surgery 12 hours ago reports increased abdominal pain and bloating. What is
the nurse’s priority action?
a. Offer a heating pad
b. Administer pain medication
✔✔c. Assess bowel sounds and inspect the abdomen
d. Encourage deep breathing exercises
A nurse walks into a room and finds a client slumped over in a chair, unresponsive but breathing.
What should the nurse do first?
a. Check blood glucose
✔✔b. Call for help and assess airway and circulation
c. Place an oxygen mask
d. Check for pupil reaction
A client refuses a blood transfusion due to religious beliefs. What is the most appropriate nursing
action?
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,✔✔a. Notify the provider and document the refusal
b. Encourage the client to reconsider
c. Call the hospital’s ethics committee
d. Begin the transfusion slowly while monitoring
A nurse finds a medication error in the chart of a patient but the client has no current adverse
symptoms. What should the nurse do first?
✔✔a. Report the error to the charge nurse and fill out an incident report
b. Notify the client’s family
c. Do nothing since the client is stable
d. Document the error but do not report
A client is scheduled for a CT scan with contrast but reports a shellfish allergy. What is the
priority nursing action?
a. Encourage fluids to help flush the contrast
✔✔b. Notify the provider before proceeding
c. Educate the client that contrast is safe
d. Ask the client to sign the consent form
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, A post-operative client refuses to use the incentive spirometer. What should the nurse do next?
a. Inform the client they must use it
✔✔b. Educate the client on the purpose and benefits of use
c. Document the refusal
d. Notify respiratory therapy
A nurse is preparing to administer insulin to a diabetic client. The dose on the MAR reads 20
units, but the vial in hand reads “U-100 insulin, 10 mL.” What is the most appropriate action?
✔✔a. Verify the correct dosage and insulin type with another nurse
b. Administer the dose quickly
c. Hold the dose and chart it
d. Notify the pharmacy for a new MAR
A client is confused and attempting to get out of bed without assistance. What should the nurse
do first?
a. Apply restraints
b. Tell the client to stay in bed
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