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1. A nurse is caring for a client experiencing shortness of breath. Which action should the
nurse take first?
A. Obtain vital signs
B. Raise the head of the bed
C. Administer prescribed medication
D. Notify the provider
Answer: B
Rationale: Positioning the client upright promotes lung expansion and improves
oxygenation immediately.
2. A nurse is delegating tasks to an assistive personnel (AP). Which task is appropriate to
delegate?
A. Assess pain level
B. Administer oral medication
C. Measure intake and output
D. Develop a care plan
Answer: C
Rationale: AP can perform routine, non-assessment tasks such as measuring intake and
output.
3. A client with heart failure reports increased shortness of breath. Which finding requires
immediate intervention?
A. Weight gain of 1 lb in 24 hr
, B. Bilateral ankle edema
C. Oxygen saturation 86%
D. Fatigue
Answer: C
Rationale: Oxygen saturation below 90% indicates impaired oxygenation and requires
prompt action.
4. A nurse is teaching a client taking warfarin. Which statement indicates understanding?
A. “I will take aspirin for headaches.”
B. “I will increase leafy green vegetables.”
C. “I will report unusual bleeding.”
D. “I can skip doses if I feel well.”
Answer: C
Rationale: Bleeding is a major adverse effect of warfarin and should be reported
immediately.
5. Which laboratory value should the nurse report immediately?
A. Potassium 2.9 mEq/L
B. Sodium 138 mEq/L
C. Calcium 9.4 mg/dL
D. Glucose 105 mg/dL
Answer: A
Rationale: Severe hypokalemia can cause life-threatening cardiac dysrhythmias.
,6. A nurse is caring for a client with diabetes mellitus. Which finding indicates
hypoglycemia?
A. Polyuria
B. Fruity breath odor
C. Diaphoresis
D. Dry skin
Answer: C
Rationale: Sweating is a common manifestation of low blood glucose.
7. Which client should the nurse assess first?
A. Client with fever of 38°C (100.4°F)
B. Client with chest pain rated 8/10
C. Client awaiting discharge
D. Client requesting pain medication
Answer: B
Rationale: Chest pain may indicate myocardial ischemia and is the highest priority.
8. A nurse is caring for a client receiving morphine IV. Which assessment is the priority?
A. Bowel sounds
B. Respiratory rate
C. Appetite
D. Skin integrity
Answer: B
, Rationale: Respiratory depression is the most serious adverse effect of opioids.
9. Which infection-control precaution is required for tuberculosis?
A. Contact
B. Droplet
C. Airborne
D. Standard
Answer: C
Rationale: TB is transmitted through airborne particles.
10. A nurse is teaching a client about a low-sodium diet. Which food should the client
avoid?
A. Fresh apple
B. Baked chicken
C. Canned soup
D. Brown rice
Answer: C
Rationale: Canned soups typically contain high amounts of sodium.
11. A client develops hives after receiving penicillin. What is the nurse’s priority action?
A. Document the reaction
B. Stop the medication
C. Increase fluids
D. Reassure the client