CORRECT ANSWERS (VERIFIED ANSWERS) Q&A
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1. A nurse is caring for a client with shortness of breath. Which
assessment should be performed first?
A. Obtain weight
B. Assess oxygen saturation
C. Check dietary intake
D. Review medications
Correct Answer: B. Assess oxygen saturation.
Rationale: Airway and breathing take priority. Oxygen
saturation helps determine the client's respiratory status
immediately.
2. Which client should the nurse assess first?
A. Client with a headache rated 4/10
B. Client requesting discharge instructions
C. Client with chest pain and diaphoresis
D. Client awaiting breakfast
Correct Answer: C. Client with chest pain and diaphoresis.
Rationale: Chest pain with sweating may indicate myocardial
infarction and requires immediate assessment.
,3. Which laboratory value should the nurse report
immediately?
A. Sodium 138 mEq/L
B. Potassium 2.8 mEq/L
C. Calcium 9.2 mg/dL
D. Glucose 100 mg/dL
Correct Answer: B. Potassium 2.8 mEq/L.
Rationale: Severe hypokalemia can cause life-threatening
cardiac dysrhythmias.
4. The nurse is teaching hand hygiene. When should alcohol-
based sanitizer not be used?
A. Before patient contact
B. After touching equipment
C. When hands are visibly soiled
D. After removing gloves
Correct Answer: C. When hands are visibly soiled.
Rationale: Soap and water are required when hands are visibly
dirty.
5. Which action best prevents patient falls?
A. Raise all four side rails
B. Keep bed in lowest position
, C. Restrict ambulation
D. Leave lights off at night
Correct Answer: B. Keep bed in lowest position.
Rationale: A low bed position reduces fall risk and injury
severity.
6. A client with diabetes reports shakiness and sweating. What
should the nurse do first?
A. Give insulin
B. Check blood glucose
C. Encourage exercise
D. Restrict fluids
Correct Answer: B. Check blood glucose.
Rationale: Symptoms suggest hypoglycemia; assessment comes
before intervention.
7. Which finding indicates effective pain management?
A. Stable blood pressure and pulse
B. Patient sleeping
C. Patient states pain is reduced
D. Family appears relaxed
Correct Answer: C. Patient states pain is reduced.