1. A nurse is caring for a patient who is scheduled for a colonoscopy.
The nurse provides instructions to the patient about the bowel
preparation regimen. Which of the following instructions should the
nurse include?
A) "You should avoid drinking any clear liquids the day before the
procedure."
B) "You should take a laxative the night before the procedure to clean
your colon."
C) "You will need to consume solid foods the day before the procedure
to prepare for the colonoscopy."
D) "You should refrain from taking any medications 24 hours before the
procedure."
Answer: B) "You should take a laxative the night before the procedure
to clean your colon."
Rationale:
For a colonoscopy, bowel preparation is necessary to ensure clear
visualization of the colon. This typically includes drinking a special
solution and/or taking a prescribed laxative the night before the
procedure. Avoiding solid foods and consuming only clear liquids 24-48
hours prior is usually recommended.
2. A nurse is assessing a patient who is 2 days post-operative following
a hip replacement. The patient complains of increased pain at the
surgical site and redness. Which of the following is the nurse's priority
action?
A) Apply a warm compress to the surgical site.
B) Administer the prescribed pain medication.
,C) Measure the patient's vital signs, including temperature.
D) Encourage the patient to perform deep breathing exercises.
Answer: C) Measure the patient's vital signs, including temperature.
Rationale:
Increased pain and redness can indicate an infection, which could lead
to sepsis or other complications. Assessing the patient's vital signs,
especially the temperature, is critical in identifying early signs of
infection. Other interventions may follow based on these findings.
3. A nurse is teaching a patient with diabetes mellitus about foot care.
Which of the following statements by the patient indicates the need
for further teaching?
A) "I will inspect my feet daily for any cuts or blisters."
B) "I will soak my feet in hot water to relax them."
C) "I should trim my toenails straight across."
D) "I will wear properly fitting shoes to prevent injury."
Answer: B) "I will soak my feet in hot water to relax them."
Rationale:
Patients with diabetes are at increased risk for foot injuries and
infections. Soaking feet in hot water can lead to burns or skin damage
due to decreased sensation. Daily foot inspection, trimming toenails
straight across, and wearing properly fitting shoes are all recommended
practices.
, 4. A nurse is caring for a patient with chronic kidney disease who is
receiving hemodialysis. The nurse notes that the patient’s blood
pressure is 86/58 mm Hg. Which of the following actions should the
nurse take first?
A) Notify the healthcare provider.
B) Increase the dialysate flow rate.
C) Slow the rate of dialysis.
D) Increase the patient’s fluid intake.
Answer: C) Slow the rate of dialysis.
Rationale:
Low blood pressure (hypotension) is a common complication during
hemodialysis, often due to fluid shifts. The nurse should slow the rate of
dialysis to help prevent further hypotension and allow for more gradual
fluid removal. The healthcare provider can be notified if the
hypotension persists or worsens.
5. A nurse is caring for a 40-year-old female patient who is newly
diagnosed with hypertension. Which of the following lifestyle changes
should the nurse recommend as the most effective strategy for
managing her condition?
A) Increasing dietary sodium intake to prevent water retention.
B) Losing weight to achieve a body mass index (BMI) within the normal
range.
C) Engaging in a high-intensity workout at least 3 times a week.
D) Reducing fluid intake to help lower blood pressure.
The nurse provides instructions to the patient about the bowel
preparation regimen. Which of the following instructions should the
nurse include?
A) "You should avoid drinking any clear liquids the day before the
procedure."
B) "You should take a laxative the night before the procedure to clean
your colon."
C) "You will need to consume solid foods the day before the procedure
to prepare for the colonoscopy."
D) "You should refrain from taking any medications 24 hours before the
procedure."
Answer: B) "You should take a laxative the night before the procedure
to clean your colon."
Rationale:
For a colonoscopy, bowel preparation is necessary to ensure clear
visualization of the colon. This typically includes drinking a special
solution and/or taking a prescribed laxative the night before the
procedure. Avoiding solid foods and consuming only clear liquids 24-48
hours prior is usually recommended.
2. A nurse is assessing a patient who is 2 days post-operative following
a hip replacement. The patient complains of increased pain at the
surgical site and redness. Which of the following is the nurse's priority
action?
A) Apply a warm compress to the surgical site.
B) Administer the prescribed pain medication.
,C) Measure the patient's vital signs, including temperature.
D) Encourage the patient to perform deep breathing exercises.
Answer: C) Measure the patient's vital signs, including temperature.
Rationale:
Increased pain and redness can indicate an infection, which could lead
to sepsis or other complications. Assessing the patient's vital signs,
especially the temperature, is critical in identifying early signs of
infection. Other interventions may follow based on these findings.
3. A nurse is teaching a patient with diabetes mellitus about foot care.
Which of the following statements by the patient indicates the need
for further teaching?
A) "I will inspect my feet daily for any cuts or blisters."
B) "I will soak my feet in hot water to relax them."
C) "I should trim my toenails straight across."
D) "I will wear properly fitting shoes to prevent injury."
Answer: B) "I will soak my feet in hot water to relax them."
Rationale:
Patients with diabetes are at increased risk for foot injuries and
infections. Soaking feet in hot water can lead to burns or skin damage
due to decreased sensation. Daily foot inspection, trimming toenails
straight across, and wearing properly fitting shoes are all recommended
practices.
, 4. A nurse is caring for a patient with chronic kidney disease who is
receiving hemodialysis. The nurse notes that the patient’s blood
pressure is 86/58 mm Hg. Which of the following actions should the
nurse take first?
A) Notify the healthcare provider.
B) Increase the dialysate flow rate.
C) Slow the rate of dialysis.
D) Increase the patient’s fluid intake.
Answer: C) Slow the rate of dialysis.
Rationale:
Low blood pressure (hypotension) is a common complication during
hemodialysis, often due to fluid shifts. The nurse should slow the rate of
dialysis to help prevent further hypotension and allow for more gradual
fluid removal. The healthcare provider can be notified if the
hypotension persists or worsens.
5. A nurse is caring for a 40-year-old female patient who is newly
diagnosed with hypertension. Which of the following lifestyle changes
should the nurse recommend as the most effective strategy for
managing her condition?
A) Increasing dietary sodium intake to prevent water retention.
B) Losing weight to achieve a body mass index (BMI) within the normal
range.
C) Engaging in a high-intensity workout at least 3 times a week.
D) Reducing fluid intake to help lower blood pressure.
