Question 1:
A nurse is caring for a client with a diagnosis of congestive heart
failure (CHF). The client is receiving a diuretic medication. Which of
the following laboratory results should the nurse prioritize to assess
the client’s status?
A) Potassium level
B) Sodium level
C) Calcium level
D) Albumin level
Answer: A) Potassium level
Rationale: Diuretics can cause the loss of potassium, leading to
hypokalemia. Monitoring potassium levels is crucial because imbalances
can result in dangerous arrhythmias.
Question 2:
A nurse is caring for a post-operative client who underwent a
cholecystectomy. The client is experiencing severe pain and nausea.
What is the nurse's first action?
A) Administer prescribed analgesics
B) Administer antiemetic medication
C) Check the client’s vital signs
D) Ask the client to rate the pain on a scale of 1-10
Answer: C) Check the client’s vital signs
Rationale: Vital signs should be checked first to assess for any changes
in the client’s condition that could be related to complications, such as
hemorrhage or infection, before administering medications.
,Question 3:
A nurse is preparing to administer an insulin injection to a client with
diabetes. The nurse notes the client has a blood sugar of 250 mg/dL.
Which of the following actions should the nurse take first?
A) Administer the prescribed insulin dose
B) Recheck the blood sugar in 30 minutes
C) Notify the healthcare provider
D) Offer the client a snack
Answer: A) Administer the prescribed insulin dose
Rationale: A blood sugar level of 250 mg/dL is elevated, and insulin
should be administered according to the prescribed dose to bring the
blood sugar down to a safe level. Reassessing or notifying the
healthcare provider may follow after administration.
Question 4:
A nurse is providing discharge teaching to a client who has a new
diagnosis of hypertension. Which of the following statements by the
client indicates the need for further teaching?
A) "I should reduce my sodium intake."
B) "I can stop taking the medication when my blood pressure is
normal."
C) "I will monitor my blood pressure regularly."
D) "I need to lose weight and exercise more."
Answer: B) "I can stop taking the medication when my blood pressure is
normal."
Rationale: Hypertension is a chronic condition, and medication should
not be stopped even when blood pressure is normal. Discontinuing
, medication without consulting a healthcare provider can result in
dangerous health consequences.
Question 5:
A nurse is caring for a client who has just returned from a
bronchoscopy procedure. Which of the following actions should the
nurse take to prevent a potential complication?
A) Assess the client’s gag reflex
B) Offer the client a cold drink
C) Administer a sedative as prescribed
D) Encourage the client to cough frequently
Answer: A) Assess the client’s gag reflex
Rationale: After a bronchoscopy, the gag reflex may be diminished due
to sedation. The nurse must assess the gag reflex before offering any
oral fluids to prevent aspiration and choking.
Question 6:
A client with a history of chronic obstructive pulmonary disease
(COPD) is admitted with acute exacerbation. The nurse should assess
for which of the following primary symptoms?
A) Cyanosis
B) Decreased breath sounds
C) Increased respiratory rate
D) Elevated blood pressure
Answer: C) Increased respiratory rate
Rationale: During an acute exacerbation of COPD, the body
compensates for hypoxia and difficulty breathing by increasing the
A nurse is caring for a client with a diagnosis of congestive heart
failure (CHF). The client is receiving a diuretic medication. Which of
the following laboratory results should the nurse prioritize to assess
the client’s status?
A) Potassium level
B) Sodium level
C) Calcium level
D) Albumin level
Answer: A) Potassium level
Rationale: Diuretics can cause the loss of potassium, leading to
hypokalemia. Monitoring potassium levels is crucial because imbalances
can result in dangerous arrhythmias.
Question 2:
A nurse is caring for a post-operative client who underwent a
cholecystectomy. The client is experiencing severe pain and nausea.
What is the nurse's first action?
A) Administer prescribed analgesics
B) Administer antiemetic medication
C) Check the client’s vital signs
D) Ask the client to rate the pain on a scale of 1-10
Answer: C) Check the client’s vital signs
Rationale: Vital signs should be checked first to assess for any changes
in the client’s condition that could be related to complications, such as
hemorrhage or infection, before administering medications.
,Question 3:
A nurse is preparing to administer an insulin injection to a client with
diabetes. The nurse notes the client has a blood sugar of 250 mg/dL.
Which of the following actions should the nurse take first?
A) Administer the prescribed insulin dose
B) Recheck the blood sugar in 30 minutes
C) Notify the healthcare provider
D) Offer the client a snack
Answer: A) Administer the prescribed insulin dose
Rationale: A blood sugar level of 250 mg/dL is elevated, and insulin
should be administered according to the prescribed dose to bring the
blood sugar down to a safe level. Reassessing or notifying the
healthcare provider may follow after administration.
Question 4:
A nurse is providing discharge teaching to a client who has a new
diagnosis of hypertension. Which of the following statements by the
client indicates the need for further teaching?
A) "I should reduce my sodium intake."
B) "I can stop taking the medication when my blood pressure is
normal."
C) "I will monitor my blood pressure regularly."
D) "I need to lose weight and exercise more."
Answer: B) "I can stop taking the medication when my blood pressure is
normal."
Rationale: Hypertension is a chronic condition, and medication should
not be stopped even when blood pressure is normal. Discontinuing
, medication without consulting a healthcare provider can result in
dangerous health consequences.
Question 5:
A nurse is caring for a client who has just returned from a
bronchoscopy procedure. Which of the following actions should the
nurse take to prevent a potential complication?
A) Assess the client’s gag reflex
B) Offer the client a cold drink
C) Administer a sedative as prescribed
D) Encourage the client to cough frequently
Answer: A) Assess the client’s gag reflex
Rationale: After a bronchoscopy, the gag reflex may be diminished due
to sedation. The nurse must assess the gag reflex before offering any
oral fluids to prevent aspiration and choking.
Question 6:
A client with a history of chronic obstructive pulmonary disease
(COPD) is admitted with acute exacerbation. The nurse should assess
for which of the following primary symptoms?
A) Cyanosis
B) Decreased breath sounds
C) Increased respiratory rate
D) Elevated blood pressure
Answer: C) Increased respiratory rate
Rationale: During an acute exacerbation of COPD, the body
compensates for hypoxia and difficulty breathing by increasing the
