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1. A nurse is caring for a client admitted with acute pancreatitis. Which laboratory
finding should the nurse expect?
A. Decreased serum amylase
B. Increased serum amylase
C. Decreased lipase
D. Decreased bilirubin
Answer: B. Increased serum amylase
Rationale: Acute pancreatitis causes inflammation of the pancreas, resulting in the release
of digestive enzymes into the bloodstream. Serum amylase and lipase levels become
elevated, with lipase remaining elevated longer than amylase. Elevated enzyme levels
support the diagnosis but should always be interpreted alongside the client's symptoms
and imaging findings.
2. A client with heart failure suddenly develops severe shortness of breath and pink
frothy sputum. What is the nurse's priority action?
A. Encourage oral fluids.
B. Place the client in a supine position.
C. Place the client in high-Fowler's position.
D. Restrict oxygen therapy.
Answer: C. Place the client in high-Fowler's position.
Rationale: Pink frothy sputum is a classic sign of acute pulmonary edema. Positioning the
client upright immediately improves lung expansion and decreases venous return to the
heart, reducing pulmonary congestion. Oxygen administration and rapid notification of the
healthcare provider should follow.
, 3. A client receiving warfarin asks why frequent blood tests are necessary. Which
response by the nurse is most appropriate?
A. "They measure your blood sugar."
B. "They monitor how long your blood takes to clot."
C. "They evaluate kidney function."
D. "They check your potassium level."
Answer: B. "They monitor how long your blood takes to clot."
Rationale: Warfarin therapy requires monitoring of the International Normalized Ratio (INR),
which measures blood clotting time. Maintaining the INR within the therapeutic range
reduces the risk of bleeding and thromboembolic complications.
4. Which assessment finding is most concerning in a client with bacterial meningitis?
A. Mild headache
B. Neck stiffness
C. Altered level of consciousness
D. Low-grade fever
Answer: C. Altered level of consciousness
Rationale: A declining level of consciousness may indicate increasing intracranial pressure
or worsening cerebral inflammation. This finding requires immediate intervention because
it can rapidly progress to coma and respiratory failure.
5. A nurse is caring for a client with chronic kidney disease. Which electrolyte
imbalance is most commonly expected?
A. Hypokalemia
B. Hyperkalemia
C. Hypocalcemia only
D. Hypernatremia
Answer: B. Hyperkalemia
Rationale: Diseased kidneys are unable to effectively excrete potassium, leading to
hyperkalemia. Elevated potassium levels can cause life-threatening cardiac dysrhythmias,
making continuous monitoring essential.
, 6. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 89%. Which action is appropriate?
A. Discontinue oxygen therapy.
B. Administer oxygen as prescribed.
C. Encourage breath-holding exercises.
D. Restrict fluid intake.
Answer: B. Administer oxygen as prescribed.
Rationale: Oxygen therapy should be administered carefully to clients with COPD, aiming
for an oxygen saturation generally between 88% and 92%, depending on provider orders.
Controlled oxygen improves tissue oxygenation while minimizing the risk of suppressing
respiratory drive in susceptible patients.
7. Which intervention helps prevent deep vein thrombosis in a postoperative client?
A. Bed rest
B. Leg massage
C. Early ambulation
D. Fluid restriction
Answer: C. Early ambulation
Rationale: Early ambulation promotes venous return, reduces venous stasis, and
significantly decreases the risk of thrombus formation. Additional preventive measures
include sequential compression devices and anticoagulant therapy when indicated.
8. A client with diabetes reports sweating, tremors, and confusion. Which action
should the nurse take first?
A. Administer insulin.
B. Check the blood glucose level.
C. Restrict carbohydrates.
D. Encourage exercise.
Answer: B. Check the blood glucose level.
Rationale: These symptoms suggest hypoglycemia. Confirming the blood glucose level
guides immediate treatment. If hypoglycemia is confirmed, the nurse should administer
fast-acting carbohydrates if the client is conscious.