Answers | Latest Version | 2025/2026 |
Correct & Verified
A nurse is caring for a client with new-onset heart failure who reports shortness of breath when
lying flat. What is the best nursing action?
A. Encourage the client to lie flat for at least 30 minutes
B. Administer a diuretic immediately without assessment
✔✔C. Elevate the head of the bed and assess respiratory status
D. Restrict fluids completely
A client with diabetes presents with nausea, vomiting, and rapid deep breathing. Which action
should the nurse take first?
A. Administer insulin as prescribed without further assessment
✔✔B. Assess blood glucose and ketone levels
C. Encourage oral intake
D. Notify dietary staff
A postoperative client has a sudden drop in blood pressure and tachycardia. What is the priority
nursing intervention?
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,A. Place the client in semi-Fowler’s position
✔✔B. Assess for signs of bleeding and maintain IV access
C. Give oral fluids
D. Encourage deep breathing
A nurse is planning care for a client with chronic kidney disease who is hyperkalemic. Which
intervention is most important?
A. Encourage increased potassium intake
✔✔B. Administer prescribed medications to lower potassium
C. Restrict fluid intake completely
D. Delay laboratory testing
A client with pneumonia develops confusion and hypotension. Which action is most appropriate?
A. Encourage rest in bed
✔✔B. Assess vital signs and oxygen saturation immediately
C. Administer antibiotics without assessment
D. Notify dietary staff
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,A nurse is caring for a client receiving IV antibiotics who develops a rash and facial swelling.
What should the nurse do first?
A. Document the reaction and continue infusion
✔✔B. Stop the infusion and notify the provider immediately
C. Apply topical cream to the rash
D. Wait to see if symptoms resolve
A client with a history of COPD is experiencing increased shortness of breath. Which
intervention has the highest priority?
A. Encourage ambulation
✔✔B. Assess respiratory status and apply oxygen as prescribed
C. Offer fluids
D. Notify dietary staff
A nurse is delegating tasks on the unit. Which task is appropriate to assign to an unlicensed
assistive personnel (UAP)?
A. Administer oral medications
B. Perform initial client assessment
✔✔C. Assist a stable client with bathing and grooming
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, D. Teach a client how to use an incentive spirometer
A client with newly diagnosed type 1 diabetes asks about preventing hypoglycemia. What is the
nurse’s best response?
A. “Only check your blood sugar if you feel shaky.”
✔✔B. “Monitor blood glucose regularly and have a source of fast-acting carbohydrate
available.”
C. “You don’t need insulin if you eat less sugar.”
D. “Hypoglycemia is not a concern in the first month.”
A nurse is assessing a client post-cataract surgery who reports sudden pain and decreased vision.
What is the priority action?
A. Reassure the client and document findings
✔✔B. Notify the provider immediately
C. Administer prescribed eye drops
D. Encourage the client to rest
A client with a nasogastric tube has abdominal distention and nausea. What is the nurse’s first
action?
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