1. A client with pneumonia has a fever of 103°F (39.4°C). Which intervention should the
nurse implement first?
A. Administer acetaminophen
B. Remove excess blankets
C. Apply a cooling blanket
D. Increase oral fluids
Answer: B. Remove excess blankets
Rationale: The first-line, least invasive intervention for fever is to remove external sources
of insulation (excess blankets and heavy clothing) to promote heat dissipation through
radiation and convection. This allows the body's natural cooling mechanisms to work. After
this non-pharmacological measure, if the fever persists, the nurse should administer an
antipyretic such as acetaminophen (A). A cooling blanket (C) is a more aggressive
intervention used for severe hyperthermia (e.g., malignant hyperthermia, heat stroke) and
is not the first choice. Increasing oral fluids (D) is important to prevent dehydration but is
not the immediate priority for reducing the fever itself.
2. A nurse is assessing a client with a chest tube after thoracic surgery. The water seal
chamber has continuous bubbling. What should the nurse do?
A. Document as normal
B. Check for an air leak
C. Clamp the chest tube immediately
D. Increase suction pressure
Answer: B. Check for an air leak
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest
tube system, meaning air is entering the pleural space from either the patient (e.g., from a
bronchopleural fistula) or from a break in the system. The nurse should first assess the
entire system for loose connections, cracks, or disconnections. If the leak is from the
patient, it may require surgical intervention. Documenting as normal (A) is incorrect
because continuous bubbling is never normal in the water seal chamber (intermittent
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,bubbling with exhalation or coughing may be normal). Clamping the chest tube
immediately (C) is dangerous because it can lead to a tension pneumothorax by trapping
air in the pleural space. Increasing suction pressure (D) will not fix an air leak and can
cause further tissue damage.
3. A client with type 2 diabetes has a fasting blood glucose of 180 mg/dL and a hemoglobin
A1c of 8.5%. Which action should the nurse take first?
A. Teach the client about insulin administration
B. Assess the client's current medication adherence and dietary patterns
C. Notify the healthcare provider for an insulin prescription
D. Instruct the client to check blood glucose four times daily
Answer: B. Assess the client's current medication adherence and dietary patterns
Rationale: Before making any changes to the treatment plan, the nurse must first perform a
thorough assessment. An A1c of 8.5% indicates poor glycemic control over the past 2-3
months (target is usually < 7%). The nurse should assess why the glucose is elevated—
non-adherence to oral medications, dietary indiscretion, lack of exercise, stress, or
intercurrent illness. After the assessment, the nurse can then plan appropriate
interventions. Teaching about insulin administration (A) may be premature if the patient
has never been on insulin; this is done only after assessment and provider order. Notifying
the provider (C) is important, but the nurse must have assessment data to report first.
Instructing the client to check blood glucose four times daily (D) is appropriate but is not
the first action; assessment of the underlying cause comes first.
4. A client with cirrhosis has ascites and an abdominal paracentesis is performed. After the
procedure, the nurse should monitor for which complication?
A. Hyperglycemia
B. Hypotension and hypovolemia
C. Hyponatremia
D. Respiratory alkalosis
Answer: B. Hypotension and hypovolemia
Rationale: Abdominal paracentesis involves the removal of large volumes of ascitic fluid
(sometimes 4-6 liters or more). This rapid removal of fluid from the peritoneal cavity can
cause a sudden shift of fluid from the intravascular space into the peritoneal cavity, leading
to hypovolemia and hypotension. This is known as post-paracentesis circulatory
dysfunction. The nurse must monitor vital signs closely for signs of shock. Hyperglycemia
(A) is not directly related to paracentesis; it is more common in liver disease due to
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,impaired glucose metabolism but not a direct complication. Hyponatremia (C) is common
in cirrhosis due to dilutional effects but is not an immediate post-procedure concern.
Respiratory alkalosis (D) is not a typical complication; the patient may experience
respiratory distress from pressure changes, but alkalosis is not expected.
5. A client with a new colostomy asks how to prevent odor. Which instruction should the
nurse provide?
A. "Place an aspirin tablet in the pouch."
B. "Eat yogurt and buttermilk regularly."
C. "Change the pouch every 4 hours."
D. "Rinse the pouch with vinegar daily."
Answer: B. "Eat yogurt and buttermilk regularly."
Rationale: Yogurt and buttermilk contain probiotics (active cultures such as Lactobacillus)
that help normalize intestinal flora and reduce the production of malodorous gases. This is
a safe, non-invasive dietary measure. Placing an aspirin (A) in the pouch is dangerous;
aspirin can irritate and cause chemical burns to the stoma mucosa. Changing the pouch
every 4 hours (C) is excessive and will cause severe skin breakdown due to frequent
adhesive removal; pouches are typically changed every 3-7 days. Rinsing the pouch with
vinegar (D) is an outdated practice that can irritate the peristomal skin and is not
recommended.
6. A nurse is caring for a client with an indwelling urinary catheter. Which finding suggests
a catheter-associated urinary tract infection (CAUTI)?
A. Clear yellow urine
B. Foul-smelling, cloudy urine with fever
C. Low back pain only
D. Urine output of 30 mL/hour
Answer: B. Foul-smelling, cloudy urine with fever
Rationale: Classic signs of a CAUTI include cloudy urine, a foul or strong odor, fever, chills,
and suprapubic or flank tenderness. The presence of bacteria, white blood cells, and pus in
the urine causes the cloudiness and odor. Clear yellow urine (A) is normal and does not
indicate infection. Low back pain only (C) is a nonspecific symptom; while it could indicate
pyelonephritis, it must be accompanied by other urinary signs to suggest CAUTI. Urine
output of 30 mL/hour (D) is within the normal range (at least 30 mL/hour) and does not
indicate infection; it suggests adequate renal perfusion.
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, 7. A client with angina pectoris reports chest pain that is relieved by rest and nitroglycerin.
The nurse recognizes this as:
A. Unstable angina
B. Variant angina
C. Stable angina
D. Myocardial infarction
Answer: C. Stable angina
Rationale: Stable angina is predictable chest pain that occurs with physical exertion,
emotional stress, or increased myocardial oxygen demand and is consistently relieved by
rest or sublingual nitroglycerin within a few minutes. It is caused by fixed coronary artery
atherosclerosis. Unstable angina (A) occurs at rest or with minimal exertion, is
unpredictable, and is not easily relieved by nitroglycerin; it is a medical emergency. Variant
angina (Prinzmetal's) (B) is caused by coronary artery spasm and often occurs at rest,
typically at night. Myocardial infarction (D) involves actual myocardial cell death; pain is
not relieved by rest or nitroglycerin and is accompanied by elevated cardiac biomarkers.
8. A nurse is preparing to administer furosemide 40 mg IV push. Which lab value should the
nurse check before administering?
A. Hemoglobin
B. Potassium
C. Platelets
D. Sodium
Answer: B. Potassium
Rationale: Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in
the ascending loop of Henle, leading to significant potassium wasting in the distal tubule.
Hypokalemia is a common and dangerous adverse effect. The nurse must check the serum
potassium level before administration; if the potassium is already low (e.g., < 3.5 mEq/L),
the nurse should hold the medication and notify the provider to prevent severe
hypokalemia, which can cause cardiac arrhythmias. Hemoglobin (A) and platelets (C) are
not directly affected by a single dose of furosemide. Sodium (D) can be affected, but
potassium is the primary and most critical value to assess prior to administration due to
the risk of life-threatening arrhythmias.
9. A client with chronic kidney disease (CKD) has a potassium level of 6.2 mEq/L. Which
intervention should the nurse implement first?
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nurse implement first?
A. Administer acetaminophen
B. Remove excess blankets
C. Apply a cooling blanket
D. Increase oral fluids
Answer: B. Remove excess blankets
Rationale: The first-line, least invasive intervention for fever is to remove external sources
of insulation (excess blankets and heavy clothing) to promote heat dissipation through
radiation and convection. This allows the body's natural cooling mechanisms to work. After
this non-pharmacological measure, if the fever persists, the nurse should administer an
antipyretic such as acetaminophen (A). A cooling blanket (C) is a more aggressive
intervention used for severe hyperthermia (e.g., malignant hyperthermia, heat stroke) and
is not the first choice. Increasing oral fluids (D) is important to prevent dehydration but is
not the immediate priority for reducing the fever itself.
2. A nurse is assessing a client with a chest tube after thoracic surgery. The water seal
chamber has continuous bubbling. What should the nurse do?
A. Document as normal
B. Check for an air leak
C. Clamp the chest tube immediately
D. Increase suction pressure
Answer: B. Check for an air leak
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest
tube system, meaning air is entering the pleural space from either the patient (e.g., from a
bronchopleural fistula) or from a break in the system. The nurse should first assess the
entire system for loose connections, cracks, or disconnections. If the leak is from the
patient, it may require surgical intervention. Documenting as normal (A) is incorrect
because continuous bubbling is never normal in the water seal chamber (intermittent
SCHOLARSOURCE 1
,bubbling with exhalation or coughing may be normal). Clamping the chest tube
immediately (C) is dangerous because it can lead to a tension pneumothorax by trapping
air in the pleural space. Increasing suction pressure (D) will not fix an air leak and can
cause further tissue damage.
3. A client with type 2 diabetes has a fasting blood glucose of 180 mg/dL and a hemoglobin
A1c of 8.5%. Which action should the nurse take first?
A. Teach the client about insulin administration
B. Assess the client's current medication adherence and dietary patterns
C. Notify the healthcare provider for an insulin prescription
D. Instruct the client to check blood glucose four times daily
Answer: B. Assess the client's current medication adherence and dietary patterns
Rationale: Before making any changes to the treatment plan, the nurse must first perform a
thorough assessment. An A1c of 8.5% indicates poor glycemic control over the past 2-3
months (target is usually < 7%). The nurse should assess why the glucose is elevated—
non-adherence to oral medications, dietary indiscretion, lack of exercise, stress, or
intercurrent illness. After the assessment, the nurse can then plan appropriate
interventions. Teaching about insulin administration (A) may be premature if the patient
has never been on insulin; this is done only after assessment and provider order. Notifying
the provider (C) is important, but the nurse must have assessment data to report first.
Instructing the client to check blood glucose four times daily (D) is appropriate but is not
the first action; assessment of the underlying cause comes first.
4. A client with cirrhosis has ascites and an abdominal paracentesis is performed. After the
procedure, the nurse should monitor for which complication?
A. Hyperglycemia
B. Hypotension and hypovolemia
C. Hyponatremia
D. Respiratory alkalosis
Answer: B. Hypotension and hypovolemia
Rationale: Abdominal paracentesis involves the removal of large volumes of ascitic fluid
(sometimes 4-6 liters or more). This rapid removal of fluid from the peritoneal cavity can
cause a sudden shift of fluid from the intravascular space into the peritoneal cavity, leading
to hypovolemia and hypotension. This is known as post-paracentesis circulatory
dysfunction. The nurse must monitor vital signs closely for signs of shock. Hyperglycemia
(A) is not directly related to paracentesis; it is more common in liver disease due to
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,impaired glucose metabolism but not a direct complication. Hyponatremia (C) is common
in cirrhosis due to dilutional effects but is not an immediate post-procedure concern.
Respiratory alkalosis (D) is not a typical complication; the patient may experience
respiratory distress from pressure changes, but alkalosis is not expected.
5. A client with a new colostomy asks how to prevent odor. Which instruction should the
nurse provide?
A. "Place an aspirin tablet in the pouch."
B. "Eat yogurt and buttermilk regularly."
C. "Change the pouch every 4 hours."
D. "Rinse the pouch with vinegar daily."
Answer: B. "Eat yogurt and buttermilk regularly."
Rationale: Yogurt and buttermilk contain probiotics (active cultures such as Lactobacillus)
that help normalize intestinal flora and reduce the production of malodorous gases. This is
a safe, non-invasive dietary measure. Placing an aspirin (A) in the pouch is dangerous;
aspirin can irritate and cause chemical burns to the stoma mucosa. Changing the pouch
every 4 hours (C) is excessive and will cause severe skin breakdown due to frequent
adhesive removal; pouches are typically changed every 3-7 days. Rinsing the pouch with
vinegar (D) is an outdated practice that can irritate the peristomal skin and is not
recommended.
6. A nurse is caring for a client with an indwelling urinary catheter. Which finding suggests
a catheter-associated urinary tract infection (CAUTI)?
A. Clear yellow urine
B. Foul-smelling, cloudy urine with fever
C. Low back pain only
D. Urine output of 30 mL/hour
Answer: B. Foul-smelling, cloudy urine with fever
Rationale: Classic signs of a CAUTI include cloudy urine, a foul or strong odor, fever, chills,
and suprapubic or flank tenderness. The presence of bacteria, white blood cells, and pus in
the urine causes the cloudiness and odor. Clear yellow urine (A) is normal and does not
indicate infection. Low back pain only (C) is a nonspecific symptom; while it could indicate
pyelonephritis, it must be accompanied by other urinary signs to suggest CAUTI. Urine
output of 30 mL/hour (D) is within the normal range (at least 30 mL/hour) and does not
indicate infection; it suggests adequate renal perfusion.
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, 7. A client with angina pectoris reports chest pain that is relieved by rest and nitroglycerin.
The nurse recognizes this as:
A. Unstable angina
B. Variant angina
C. Stable angina
D. Myocardial infarction
Answer: C. Stable angina
Rationale: Stable angina is predictable chest pain that occurs with physical exertion,
emotional stress, or increased myocardial oxygen demand and is consistently relieved by
rest or sublingual nitroglycerin within a few minutes. It is caused by fixed coronary artery
atherosclerosis. Unstable angina (A) occurs at rest or with minimal exertion, is
unpredictable, and is not easily relieved by nitroglycerin; it is a medical emergency. Variant
angina (Prinzmetal's) (B) is caused by coronary artery spasm and often occurs at rest,
typically at night. Myocardial infarction (D) involves actual myocardial cell death; pain is
not relieved by rest or nitroglycerin and is accompanied by elevated cardiac biomarkers.
8. A nurse is preparing to administer furosemide 40 mg IV push. Which lab value should the
nurse check before administering?
A. Hemoglobin
B. Potassium
C. Platelets
D. Sodium
Answer: B. Potassium
Rationale: Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in
the ascending loop of Henle, leading to significant potassium wasting in the distal tubule.
Hypokalemia is a common and dangerous adverse effect. The nurse must check the serum
potassium level before administration; if the potassium is already low (e.g., < 3.5 mEq/L),
the nurse should hold the medication and notify the provider to prevent severe
hypokalemia, which can cause cardiac arrhythmias. Hemoglobin (A) and platelets (C) are
not directly affected by a single dose of furosemide. Sodium (D) can be affected, but
potassium is the primary and most critical value to assess prior to administration due to
the risk of life-threatening arrhythmias.
9. A client with chronic kidney disease (CKD) has a potassium level of 6.2 mEq/L. Which
intervention should the nurse implement first?
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