1. A nurse is caring for a postoperative patient who has a history of
hypertension. Which of the following interventions should the nurse
prioritize to prevent complications?
A) Administer antihypertensive medications as prescribed.
B) Encourage the patient to ambulate early postoperatively.
C) Monitor the patient's blood pressure regularly.
D) Provide the patient with a low-salt diet.
Answer: C) Monitor the patient's blood pressure regularly.
Rationale: Postoperative patients are at risk for blood pressure
fluctuations. Monitoring blood pressure regularly allows early detection
of hypertension or hypotension, which could indicate complications
such as bleeding or fluid imbalance. Although antihypertensive
medications (A) and a low-salt diet (D) may be important, regular blood
pressure monitoring is the priority to prevent immediate postoperative
complications. Early ambulation (B) is important for recovery but not a
priority for managing hypertension.
2. A nurse is assessing a patient with acute pancreatitis. Which of the
following findings is most indicative of worsening pancreatitis?
A) Decreased bowel sounds
B) Severe, unrelenting abdominal pain
C) Mild jaundice
D) Increased urine output
Answer: B) Severe, unrelenting abdominal pain
Rationale: Severe, unrelenting abdominal pain is the most significant
indicator of worsening acute pancreatitis, often signaling complications
like pancreatic necrosis or pseudocyst formation. Decreased bowel
,sounds (A) can be seen in pancreatitis but are not as indicative of
worsening disease. Mild jaundice (C) and increased urine output (D) are
not typical signs of worsening pancreatitis.
3. A nurse is preparing to administer a blood transfusion to a client.
Which of the following actions is the most important for the nurse to
take before starting the transfusion?
A) Verify the client’s identity using two identifiers.
B) Warm the blood to room temperature before infusing.
C) Administer a diuretic before starting the transfusion.
D) Prime the transfusion tubing with normal saline.
Answer: A) Verify the client’s identity using two identifiers.
Rationale: The most important action to prevent a transfusion error is
to verify the client's identity using two identifiers (such as name and
date of birth). This ensures the correct blood product is given to the
correct patient. Warming the blood (B) is not generally required unless
the blood is very cold. Administering a diuretic (C) is not a standard pre-
transfusion procedure, and priming the tubing with normal saline (D) is
typically done, but verifying identity is the priority.
4. A nurse is providing discharge teaching to a client who has been
prescribed a bronchodilator. Which statement by the client indicates a
need for further teaching?
A) “I will take this medication as prescribed even when I feel better.”
B) “I should use this medication only when I have difficulty breathing.”
C) “I should rinse my mouth after using this medication.”
D) “I will avoid using the medication with my other inhalers.”
, Answer: B) “I should use this medication only when I have difficulty
breathing.”
Rationale: Bronchodilators, particularly rescue inhalers, are used to
prevent bronchospasm and should be used as prescribed, even when
the client is not experiencing acute symptoms. The statement "I should
use this medication only when I have difficulty breathing" indicates a
misunderstanding. The medication should be used as part of a
comprehensive treatment plan, not just during acute episodes. Rinsing
the mouth (C) helps prevent oral candidiasis, and avoiding drug
interactions with other inhalers (D) is generally correct.
5. A nurse is caring for a client who is 4 hours postoperative following
a total hip replacement. Which of the following actions should the
nurse take to prevent a hip dislocation?
A) Instruct the client to avoid flexing the hip more than 90 degrees.
B) Encourage the client to perform leg exercises every 2 hours.
C) Place a pillow between the client’s knees when turning.
D) Instruct the client to sit with the legs crossed.
Answer: A) Instruct the client to avoid flexing the hip more than 90
degrees.
Rationale: After a total hip replacement, preventing hip dislocation is
crucial. Flexing the hip more than 90 degrees can increase the risk of
dislocation. Placing a pillow between the knees (C) when turning also
helps prevent dislocation, but the key focus for preventing dislocation is
avoiding excessive hip flexion. Leg exercises (B) are important for
circulation and mobility but not specific to preventing dislocation, and
sitting with legs crossed (D) can cause dislocation.
hypertension. Which of the following interventions should the nurse
prioritize to prevent complications?
A) Administer antihypertensive medications as prescribed.
B) Encourage the patient to ambulate early postoperatively.
C) Monitor the patient's blood pressure regularly.
D) Provide the patient with a low-salt diet.
Answer: C) Monitor the patient's blood pressure regularly.
Rationale: Postoperative patients are at risk for blood pressure
fluctuations. Monitoring blood pressure regularly allows early detection
of hypertension or hypotension, which could indicate complications
such as bleeding or fluid imbalance. Although antihypertensive
medications (A) and a low-salt diet (D) may be important, regular blood
pressure monitoring is the priority to prevent immediate postoperative
complications. Early ambulation (B) is important for recovery but not a
priority for managing hypertension.
2. A nurse is assessing a patient with acute pancreatitis. Which of the
following findings is most indicative of worsening pancreatitis?
A) Decreased bowel sounds
B) Severe, unrelenting abdominal pain
C) Mild jaundice
D) Increased urine output
Answer: B) Severe, unrelenting abdominal pain
Rationale: Severe, unrelenting abdominal pain is the most significant
indicator of worsening acute pancreatitis, often signaling complications
like pancreatic necrosis or pseudocyst formation. Decreased bowel
,sounds (A) can be seen in pancreatitis but are not as indicative of
worsening disease. Mild jaundice (C) and increased urine output (D) are
not typical signs of worsening pancreatitis.
3. A nurse is preparing to administer a blood transfusion to a client.
Which of the following actions is the most important for the nurse to
take before starting the transfusion?
A) Verify the client’s identity using two identifiers.
B) Warm the blood to room temperature before infusing.
C) Administer a diuretic before starting the transfusion.
D) Prime the transfusion tubing with normal saline.
Answer: A) Verify the client’s identity using two identifiers.
Rationale: The most important action to prevent a transfusion error is
to verify the client's identity using two identifiers (such as name and
date of birth). This ensures the correct blood product is given to the
correct patient. Warming the blood (B) is not generally required unless
the blood is very cold. Administering a diuretic (C) is not a standard pre-
transfusion procedure, and priming the tubing with normal saline (D) is
typically done, but verifying identity is the priority.
4. A nurse is providing discharge teaching to a client who has been
prescribed a bronchodilator. Which statement by the client indicates a
need for further teaching?
A) “I will take this medication as prescribed even when I feel better.”
B) “I should use this medication only when I have difficulty breathing.”
C) “I should rinse my mouth after using this medication.”
D) “I will avoid using the medication with my other inhalers.”
, Answer: B) “I should use this medication only when I have difficulty
breathing.”
Rationale: Bronchodilators, particularly rescue inhalers, are used to
prevent bronchospasm and should be used as prescribed, even when
the client is not experiencing acute symptoms. The statement "I should
use this medication only when I have difficulty breathing" indicates a
misunderstanding. The medication should be used as part of a
comprehensive treatment plan, not just during acute episodes. Rinsing
the mouth (C) helps prevent oral candidiasis, and avoiding drug
interactions with other inhalers (D) is generally correct.
5. A nurse is caring for a client who is 4 hours postoperative following
a total hip replacement. Which of the following actions should the
nurse take to prevent a hip dislocation?
A) Instruct the client to avoid flexing the hip more than 90 degrees.
B) Encourage the client to perform leg exercises every 2 hours.
C) Place a pillow between the client’s knees when turning.
D) Instruct the client to sit with the legs crossed.
Answer: A) Instruct the client to avoid flexing the hip more than 90
degrees.
Rationale: After a total hip replacement, preventing hip dislocation is
crucial. Flexing the hip more than 90 degrees can increase the risk of
dislocation. Placing a pillow between the knees (C) when turning also
helps prevent dislocation, but the key focus for preventing dislocation is
avoiding excessive hip flexion. Leg exercises (B) are important for
circulation and mobility but not specific to preventing dislocation, and
sitting with legs crossed (D) can cause dislocation.
