Answers | Latest Version | 2025/2026 |
Correct & Verified
A nurse is assessing a client who is postoperative. Which of the following findings should the
nurse report immediately?
A. Pain score of 4 out of 10
B. Urinary output of 60 mL/hr
✔✔ C. Respiratory rate of 10/min
D. Blood pressure of 120/80 mm Hg
A nurse is caring for a client who has a new prescription for furosemide. Which of the following
findings should the nurse report to the provider?
A. Weight loss of 2 kg in one week
B. Potassium level of 4.0 mEq/L
✔✔ C. Tinnitus and hearing loss
D. Urine output of 1,200 mL per day
A client with diabetes mellitus reports shakiness and sweating. Which of the following is the
nurse’s priority action?
1
,A. Encourage rest and relaxation
✔✔ B. Check the client’s blood glucose
C. Notify the provider
D. Administer long-acting insulin
A nurse is teaching a client how to self-administer enoxaparin. Which of the following
instructions should the nurse include?
A. Aspirate before injecting the medication
B. Massage the site after injection
✔✔ C. Inject into the abdomen at a 90-degree angle
D. Use the same site for each injection
A nurse is reinforcing teaching about crutch walking using a three-point gait. Which of the
following should the client do first?
A. Move the unaffected leg forward
✔✔ B. Move both crutches and the affected leg forward together
C. Move both legs forward together
D. Move the affected leg and one crutch forward
2
,A client receiving total parenteral nutrition (TPN) is showing signs of restlessness and difficulty
breathing. What is the nurse’s priority action?
A. Stop the TPN infusion
✔✔ B. Check the client’s blood glucose level
C. Elevate the head of the bed
D. Monitor the infusion rate
A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of
the following findings should the nurse report to the provider?
A. Absent bowel sounds
✔✔ B. Wound edges pulling apart
C. Pain at incision site
D. Temperature of 37.5°C (99.5°F)
A client with COPD reports increasing shortness of breath. Which of the following oxygen
delivery systems is most appropriate?
✔✔ A. Nasal cannula at 2 L/min
B. Non-rebreather mask at 15 L/min
3
, C. Simple face mask at 8 L/min
D. Venturi mask at 6 L/min
A nurse is planning care for a client with a pressure ulcer on the heel. Which intervention should
the nurse implement?
✔✔ A. Elevate the heel off the bed surface
B. Massage the area twice daily
C. Apply a heating pad
D. Clean with hydrogen peroxide
A nurse is providing discharge teaching to a client with a new prescription for warfarin. Which
statement indicates understanding?
A. "I will take aspirin for pain relief."
✔✔ B. "I will use a soft-bristled toothbrush."
C. "I will eat more spinach for vitamin K."
D. "I can take ibuprofen for headaches."
A client with heart failure is receiving furosemide. Which of the following findings indicates a
potential adverse effect?
4