1. A nurse is caring for a client who is post-operative and receiving
opioid analgesics for pain management. The nurse notes that the
client's respiratory rate is 8 breaths/min. What is the priority action
the nurse should take?
a) Increase the client's oxygen flow rate
b) Administer naloxone
c) Notify the healthcare provider
d) Increase the dose of opioid analgesic
Answer: b) Administer naloxone
Rationale: A respiratory rate of 8 breaths per minute is dangerously low,
and opioid overdose is a potential cause. Naloxone is an opioid
antagonist that can reverse respiratory depression caused by opioids,
making it the priority intervention.
2. A nurse is assessing a newborn and notes the presence of a
"mottled" appearance on the skin. The nurse understands that this
finding is:
a) A sign of hypothermia
b) A sign of dehydration
c) Normal in a newborn
d) A sign of infection
Answer: c) Normal in a newborn
Rationale: Mottling of the skin is a common finding in newborns and
can be related to poor circulation or the body's adjustment to
temperature regulation. It is usually not a sign of pathology unless
accompanied by other symptoms.
,3. A nurse is caring for a client with a history of hypertension who is
prescribed a diuretic. Which of the following assessments is the
nurse's priority?
a) Monitoring the client's blood glucose levels
b) Measuring the client's blood pressure
c) Assessing the client's urine output
d) Monitoring the client's weight
Answer: b) Measuring the client's blood pressure
Rationale: Since the client has hypertension and is taking a diuretic, the
nurse must prioritize monitoring blood pressure to ensure the
medication is effectively managing the hypertension and not causing
hypotension.
4. A nurse is educating a client who has been prescribed an inhaled
corticosteroid for asthma. Which of the following instructions is most
important for the nurse to include in the teaching?
a) "Take this medication on an empty stomach for the best absorption."
b) "Rinse your mouth after each use to prevent oral thrush."
c) "Avoid drinking fluids after using the inhaler."
d) "You should increase the dose if you experience increased
symptoms."
Answer: b) "Rinse your mouth after each use to prevent oral thrush."
Rationale: Inhaled corticosteroids can cause fungal infections in the
mouth (oral thrush). Rinsing the mouth after each use helps prevent
this complication.
, 5. A nurse is caring for a client who has recently been diagnosed with
type 1 diabetes. The nurse provides education about insulin therapy.
Which statement by the client indicates the need for further teaching?
a) "I will inject my insulin into the fatty tissue of my abdomen or
thighs."
b) "I will rotate injection sites to avoid tissue damage."
c) "I will only adjust my insulin dose if my blood sugar is too high."
d) "I will carry a source of sugar with me in case I experience
hypoglycemia."
Answer: c) "I will only adjust my insulin dose if my blood sugar is too
high."
Rationale: Insulin doses should be adjusted based on blood glucose
levels, but they can be adjusted for both high and low blood glucose
levels. The client should be educated on adjusting insulin doses
appropriately to maintain a safe blood sugar level.
6. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). The nurse notes that the client is using pursed-lip
breathing. The nurse recognizes that this technique is intended to:
a) Increase oxygen intake
b) Promote gas exchange and improve ventilation
c) Prevent airway constriction
d) Provide more efficient lung expansion
Answer: b) Promote gas exchange and improve ventilation
Rationale: Pursed-lip breathing helps reduce the work of breathing,
promotes exhalation, and improves ventilation by allowing airways to
opioid analgesics for pain management. The nurse notes that the
client's respiratory rate is 8 breaths/min. What is the priority action
the nurse should take?
a) Increase the client's oxygen flow rate
b) Administer naloxone
c) Notify the healthcare provider
d) Increase the dose of opioid analgesic
Answer: b) Administer naloxone
Rationale: A respiratory rate of 8 breaths per minute is dangerously low,
and opioid overdose is a potential cause. Naloxone is an opioid
antagonist that can reverse respiratory depression caused by opioids,
making it the priority intervention.
2. A nurse is assessing a newborn and notes the presence of a
"mottled" appearance on the skin. The nurse understands that this
finding is:
a) A sign of hypothermia
b) A sign of dehydration
c) Normal in a newborn
d) A sign of infection
Answer: c) Normal in a newborn
Rationale: Mottling of the skin is a common finding in newborns and
can be related to poor circulation or the body's adjustment to
temperature regulation. It is usually not a sign of pathology unless
accompanied by other symptoms.
,3. A nurse is caring for a client with a history of hypertension who is
prescribed a diuretic. Which of the following assessments is the
nurse's priority?
a) Monitoring the client's blood glucose levels
b) Measuring the client's blood pressure
c) Assessing the client's urine output
d) Monitoring the client's weight
Answer: b) Measuring the client's blood pressure
Rationale: Since the client has hypertension and is taking a diuretic, the
nurse must prioritize monitoring blood pressure to ensure the
medication is effectively managing the hypertension and not causing
hypotension.
4. A nurse is educating a client who has been prescribed an inhaled
corticosteroid for asthma. Which of the following instructions is most
important for the nurse to include in the teaching?
a) "Take this medication on an empty stomach for the best absorption."
b) "Rinse your mouth after each use to prevent oral thrush."
c) "Avoid drinking fluids after using the inhaler."
d) "You should increase the dose if you experience increased
symptoms."
Answer: b) "Rinse your mouth after each use to prevent oral thrush."
Rationale: Inhaled corticosteroids can cause fungal infections in the
mouth (oral thrush). Rinsing the mouth after each use helps prevent
this complication.
, 5. A nurse is caring for a client who has recently been diagnosed with
type 1 diabetes. The nurse provides education about insulin therapy.
Which statement by the client indicates the need for further teaching?
a) "I will inject my insulin into the fatty tissue of my abdomen or
thighs."
b) "I will rotate injection sites to avoid tissue damage."
c) "I will only adjust my insulin dose if my blood sugar is too high."
d) "I will carry a source of sugar with me in case I experience
hypoglycemia."
Answer: c) "I will only adjust my insulin dose if my blood sugar is too
high."
Rationale: Insulin doses should be adjusted based on blood glucose
levels, but they can be adjusted for both high and low blood glucose
levels. The client should be educated on adjusting insulin doses
appropriately to maintain a safe blood sugar level.
6. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). The nurse notes that the client is using pursed-lip
breathing. The nurse recognizes that this technique is intended to:
a) Increase oxygen intake
b) Promote gas exchange and improve ventilation
c) Prevent airway constriction
d) Provide more efficient lung expansion
Answer: b) Promote gas exchange and improve ventilation
Rationale: Pursed-lip breathing helps reduce the work of breathing,
promotes exhalation, and improves ventilation by allowing airways to
