Latest Version | 2025/2026 | Correct &
Verified
A nurse is caring for a client with pneumonia who is receiving oxygen therapy. Which action is
most appropriate?
A. Encourage the client to lie flat in bed
B. Apply oxygen at the highest setting possible
✔✔C. Monitor oxygen saturation and adjust flow as prescribed
D. Restrict fluid intake to prevent pulmonary edema
A client reports chest pain radiating to the left arm. What is the nurse’s first action?
A. Provide a warm compress to the chest
✔✔B. Assess vital signs and apply cardiac monitoring
C. Encourage the client to take deep breaths
D. Administer an analgesic immediately
A nurse is preparing to administer a new antibiotic to a client with renal impairment. What is the
priority action?
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,A. Administer the full dose regardless of kidney function
✔✔B. Check renal function and adjust the dose if needed
C. Give the medication with food
D. Skip the dose if the client feels fine
A client with diabetes reports dizziness and sweating. What should the nurse do first?
A. Encourage the client to walk around
✔✔B. Check blood glucose and administer a quick-acting carbohydrate if low
C. Hold insulin for the day
D. Notify the provider immediately
A patient with a Foley catheter develops cloudy urine and fever. What is the priority nursing
action?
A. Change the catheter immediately
✔✔B. Assess for urinary tract infection and notify the provider
C. Encourage oral hydration only
D. Apply a warm compress to the bladder
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,A nurse observes a client with COPD using accessory muscles and having labored breathing.
What is the first action?
✔✔A. Assess oxygen saturation and administer prescribed oxygen
B. Encourage the client to cough harder
C. Have the client lie flat in bed
D. Restrict fluid intake
A client is post-operative and reports pain at 9/10 on the pain scale. What is the priority action?
A. Encourage deep breathing and ambulation first
✔✔B. Assess the pain and administer prescribed analgesics
C. Document the pain and reassess in 2 hours
D. Wait to see if the pain decreases naturally
A nurse is caring for a client with heart failure who is short of breath. What action is most
appropriate?
A. Place the client flat in bed
✔✔B. Elevate the head of the bed and monitor oxygen saturation
C. Restrict fluids completely
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, D. Encourage heavy exercise
A patient is receiving IV potassium. Which assessment is most important?
A. Monitor for edema only
✔✔B. Assess for cardiac arrhythmias
C. Encourage oral potassium supplements
D. Restrict fluid intake
A nurse notes a child with sudden onset of high fever and seizure activity. What is the first
action?
A. Place the child in a supine position
✔✔B. Ensure airway safety and maintain seizure precautions
C. Start IV fluids immediately
D. Administer antipyretics only
A nurse is preparing to administer a blood transfusion. What is the most important safety step?
A. Check the patient’s allergies only
B. Begin the transfusion immediately
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