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1. A client with a history of heart failure is prescribed furosemide.
Which assessment finding indicates that the medication is having
the desired therapeutic effect?
A) Increased blood pressure
B) Weight gain of 2 pounds in 24 hours
C) Clear breath sounds
D) 1+ pedal edema
Answer: C
2. The nurse is preparing to insert a nasogastric tube. In which
position should the client be placed to facilitate insertion?
A) Supine with the head flat
B) Left side-lying with the head elevated
C) High Fowler's position with the head tilted forward
D) Trendelenburg position
Answer: C
3. A client who is postoperative day 1 after abdominal surgery
complains of incisional pain. Which action should the nurse take
,first?
A) Administer the prescribed PRN analgesic.
B) Reposition the client to a more comfortable position.
C) Assess the incision for redness, swelling, or drainage.
D) Encourage the client to use deep breathing and relaxation
techniques.
Answer: C
4. Which instruction should the nurse include when teaching a
client how to use an incentive spirometer?
A) Inhale as deeply and as quickly as possible.
B) Exhale forcefully into the mouthpiece.
C) Hold the breath for 2 to 3 seconds after inhaling.
D) Use the device every 8 hours.
Answer: C
5. The nurse is assessing a client who is receiving a blood
transfusion. Which finding indicates a possible transfusion
reaction and requires immediate action?
A) Slight increase in heart rate
B) Flank pain and chills
C) Mild headache
D) Slight decrease in blood pressure
Answer: B
,6. A client with a new colostomy is concerned about the
appearance of the stoma. Which statement indicates that the
client understands the nurse's teaching?
A) "The stoma will shrink in size over the next few weeks."
B) "A purple-colored stoma is a sign of healing."
C) "I should expect the stoma to bleed easily when touched."
D) "The stoma should be moist and pinkish-red in color."
Answer: D
7. The healthcare provider prescribes 1000 mL of normal saline to
infuse over 8 hours. The drop factor is 15 gtt/mL. At how many
drops per minute should the nurse set the IV flow rate? (Round to
the nearest whole number.)
A) 31 gtt/min
B) 21 gtt/min
C) 42 gtt/min
D) 52 gtt/min
Answer: A
8. Which finding is the earliest sign of hypoxemia in a client?
A) Cyanosis
B) Restlessness
C) Bradycardia
D) Hypertension
Answer: B
, 9. The nurse is providing discharge teaching to a client who is
prescribed warfarin. Which statement by the client indicates a
need for further teaching?
A) "I will avoid eating large amounts of leafy green vegetables."
B) "I should use an electric razor for shaving."
C) "I can take ibuprofen for headaches."
D) "I will report any unusual bleeding or bruising to my
healthcare provider."
Answer: C
10. The nurse is caring for a client with a nasogastric tube
attached to low intermittent suction. Which assessment finding
indicates that the tube is functioning properly?
A) The client complains of nausea.
B) The drainage is bright red.
C) The pH of the gastric aspirate is 5.0.
D) The abdomen is soft and non-distended.
Answer: D
11. A client is admitted with a diagnosis of dehydration. Which
laboratory value supports this diagnosis?
A) Serum sodium of 140 mEq/L
B) Serum potassium of 4.0 mEq/L
C) Serum osmolality of 295 mOsm/kg