1. A nurse is caring for a postoperative patient who is at risk for deep
vein thrombosis (DVT). Which intervention is most important to
prevent this complication?
A. Apply a warm compress to the affected leg
B. Encourage the patient to remain in bed and rest
C. Administer anticoagulants as prescribed
D. Ensure the patient wears compression stockings as ordered
Answer: D. Ensure the patient wears compression stockings as ordered
Rationale: Compression stockings help to promote venous return,
preventing blood stasis and reducing the risk of DVT. Other
interventions, like anticoagulants, may also be used, but ensuring
proper use of compression stockings is a key preventative measure.
2. A nurse is teaching a client who is newly diagnosed with
hypertension. Which statement by the client indicates a need for
further teaching?
A. "I will reduce my salt intake."
B. "I will take my medications even if I feel fine."
C. "I should avoid exercise to keep my blood pressure low."
D. "I will monitor my blood pressure regularly."
Answer: C. "I should avoid exercise to keep my blood pressure low."
Rationale: Regular exercise is important for managing hypertension.
Physical activity helps lower blood pressure and improves
cardiovascular health. Avoiding exercise would not be recommended
for hypertension management.
,3. A nurse is preparing to administer an oral medication to a client
with dysphagia. What should the nurse do first?
A. Crush the tablet and mix it with applesauce
B. Administer the medication with a thickened liquid
C. Place the medication in the client’s mouth without water
D. Consult the healthcare provider for an alternative medication
Answer: B. Administer the medication with a thickened liquid
Rationale: For clients with dysphagia, it is safer to administer
medications with thickened liquids to reduce the risk of aspiration.
Crushing tablets or opening capsules may not be appropriate unless
specifically instructed by the healthcare provider.
4. The nurse is caring for a 4-year-old child with asthma. Which action
by the nurse is most appropriate?
A. Instruct the child to breathe through the mouth to clear the airways
B. Teach the child how to use a spacer with the inhaler
C. Limit the child’s fluid intake to avoid coughing
D. Encourage the child to rest and avoid physical activity
Answer: B. Teach the child how to use a spacer with the inhaler
Rationale: A spacer with an inhaler improves the delivery of the
medication to the lungs and is especially beneficial for young children
who may have difficulty using an inhaler correctly. Ensuring proper
inhaler technique is crucial for effective asthma management.
5. A nurse is caring for a patient with chronic obstructive pulmonary
disease (COPD). The patient has an oxygen saturation of 88%. What is
the most appropriate nursing action?
, A. Increase the oxygen flow rate to 6L/min
B. Administer a bronchodilator as prescribed
C. Encourage the patient to take deep breaths
D. Reassure the patient that this is normal for COPD
Answer: B. Administer a bronchodilator as prescribed
Rationale: In COPD patients, bronchodilators help relieve
bronchospasm and improve airflow. While oxygen therapy might be
needed, it is more important to address the airway constriction with
bronchodilators first. Increasing oxygen without addressing airway
issues may not be effective.
6. A nurse is caring for a patient with a recent myocardial infarction
(MI). Which finding indicates a complication that requires immediate
intervention?
A. Blood pressure of 110/70 mmHg
B. Heart rate of 90 beats per minute
C. Chest pain unrelieved by nitroglycerin
D. Respiratory rate of 18 breaths per minute
Answer: C. Chest pain unrelieved by nitroglycerin
Rationale: Chest pain unrelieved by nitroglycerin may indicate ongoing
ischemia or a more severe complication, such as a myocardial infarction
complication, requiring immediate intervention. This is an emergency
situation that warrants immediate medical attention.
7. A nurse is teaching a patient with diabetes about foot care. Which
statement indicates the patient needs further teaching?
vein thrombosis (DVT). Which intervention is most important to
prevent this complication?
A. Apply a warm compress to the affected leg
B. Encourage the patient to remain in bed and rest
C. Administer anticoagulants as prescribed
D. Ensure the patient wears compression stockings as ordered
Answer: D. Ensure the patient wears compression stockings as ordered
Rationale: Compression stockings help to promote venous return,
preventing blood stasis and reducing the risk of DVT. Other
interventions, like anticoagulants, may also be used, but ensuring
proper use of compression stockings is a key preventative measure.
2. A nurse is teaching a client who is newly diagnosed with
hypertension. Which statement by the client indicates a need for
further teaching?
A. "I will reduce my salt intake."
B. "I will take my medications even if I feel fine."
C. "I should avoid exercise to keep my blood pressure low."
D. "I will monitor my blood pressure regularly."
Answer: C. "I should avoid exercise to keep my blood pressure low."
Rationale: Regular exercise is important for managing hypertension.
Physical activity helps lower blood pressure and improves
cardiovascular health. Avoiding exercise would not be recommended
for hypertension management.
,3. A nurse is preparing to administer an oral medication to a client
with dysphagia. What should the nurse do first?
A. Crush the tablet and mix it with applesauce
B. Administer the medication with a thickened liquid
C. Place the medication in the client’s mouth without water
D. Consult the healthcare provider for an alternative medication
Answer: B. Administer the medication with a thickened liquid
Rationale: For clients with dysphagia, it is safer to administer
medications with thickened liquids to reduce the risk of aspiration.
Crushing tablets or opening capsules may not be appropriate unless
specifically instructed by the healthcare provider.
4. The nurse is caring for a 4-year-old child with asthma. Which action
by the nurse is most appropriate?
A. Instruct the child to breathe through the mouth to clear the airways
B. Teach the child how to use a spacer with the inhaler
C. Limit the child’s fluid intake to avoid coughing
D. Encourage the child to rest and avoid physical activity
Answer: B. Teach the child how to use a spacer with the inhaler
Rationale: A spacer with an inhaler improves the delivery of the
medication to the lungs and is especially beneficial for young children
who may have difficulty using an inhaler correctly. Ensuring proper
inhaler technique is crucial for effective asthma management.
5. A nurse is caring for a patient with chronic obstructive pulmonary
disease (COPD). The patient has an oxygen saturation of 88%. What is
the most appropriate nursing action?
, A. Increase the oxygen flow rate to 6L/min
B. Administer a bronchodilator as prescribed
C. Encourage the patient to take deep breaths
D. Reassure the patient that this is normal for COPD
Answer: B. Administer a bronchodilator as prescribed
Rationale: In COPD patients, bronchodilators help relieve
bronchospasm and improve airflow. While oxygen therapy might be
needed, it is more important to address the airway constriction with
bronchodilators first. Increasing oxygen without addressing airway
issues may not be effective.
6. A nurse is caring for a patient with a recent myocardial infarction
(MI). Which finding indicates a complication that requires immediate
intervention?
A. Blood pressure of 110/70 mmHg
B. Heart rate of 90 beats per minute
C. Chest pain unrelieved by nitroglycerin
D. Respiratory rate of 18 breaths per minute
Answer: C. Chest pain unrelieved by nitroglycerin
Rationale: Chest pain unrelieved by nitroglycerin may indicate ongoing
ischemia or a more severe complication, such as a myocardial infarction
complication, requiring immediate intervention. This is an emergency
situation that warrants immediate medical attention.
7. A nurse is teaching a patient with diabetes about foot care. Which
statement indicates the patient needs further teaching?
