1. Which of the following is the most important initial action for a
nurse when caring for a client who has just been admitted with severe
burns?
A. Assess the burn wound for signs of infection.
B. Administer pain medications.
C. Establish an airway and provide oxygen.
D. Apply a sterile dressing to the burn area.
Answer: C. Establish an airway and provide oxygen.
Rationale:
The priority in burn management is to ensure the client’s airway is
patent and to provide oxygenation. Airway management is the first step
to prevent hypoxia and further complications. Other actions like
assessing for infection or applying dressings are important but not as
immediate as ensuring adequate ventilation.
2. A nurse is caring for a client with diabetes mellitus. The client
reports feeling shaky, sweating, and dizzy. What is the nurse's priority
action?
A. Check the client’s blood glucose level.
B. Administer insulin as prescribed.
C. Offer the client a high-protein snack.
D. Notify the healthcare provider.
Answer: A. Check the client’s blood glucose level.
Rationale:
Shakiness, sweating, and dizziness are signs of hypoglycemia. The first
action should be to check the client’s blood glucose to confirm if
hypoglycemia is the cause. If the blood glucose is low, the nurse can
,administer the appropriate treatment, such as a quick source of
glucose.
3. Which of the following nursing interventions is most appropriate for
a client with chronic obstructive pulmonary disease (COPD) during an
acute exacerbation?
A. Encourage the client to cough forcefully.
B. Administer oxygen to maintain oxygen saturation of 92-98%.
C. Place the client in the supine position for comfort.
D. Restrict fluid intake to prevent fluid retention.
Answer: B. Administer oxygen to maintain oxygen saturation of 92-
98%.
Rationale:
In COPD exacerbations, oxygen therapy is crucial to maintain adequate
oxygenation. The goal is to maintain oxygen saturation between 92-
98%. Coughing forcefully and restricting fluids are not recommended
during an acute exacerbation, and the client should not be placed in the
supine position due to the risk of increasing respiratory distress.
4. A nurse is caring for a client who is receiving chemotherapy. The
client’s white blood cell count is 2,000/mm³. Which of the following
actions should the nurse take first?
A. Place the client on contact precautions.
B. Administer the prescribed granulocyte colony-stimulating factor.
C. Encourage the client to avoid crowded places.
D. Prepare the client for a blood transfusion.
Answer: C. Encourage the client to avoid crowded places.
, Rationale:
A low white blood cell count (neutropenia) increases the risk of
infection. The priority is to reduce exposure to infectious agents, such
as advising the client to avoid crowded places. The other actions
(precautions, medications, and transfusions) are also important but
secondary.
5. A nurse is caring for a patient who is post-operative following a
total hip replacement. The nurse notes that the client has severe pain
in the left hip, and the leg appears shortened and externally rotated.
What should the nurse suspect?
A. Hip dislocation
B. Infection
C. Deep vein thrombosis
D. Pulmonary embolism
Answer: A. Hip dislocation
Rationale:
A shortened, externally rotated leg following hip replacement surgery is
a classic sign of hip dislocation. Immediate intervention is necessary to
prevent further injury and complications. The other options may also be
possible but do not typically present with this specific combination of
signs and symptoms.
6. Which of the following is the most important action for the nurse
when caring for a client with an indwelling urinary catheter?
A. Remove the catheter as soon as possible to prevent infection.
B. Clean the catheter insertion site with alcohol.
nurse when caring for a client who has just been admitted with severe
burns?
A. Assess the burn wound for signs of infection.
B. Administer pain medications.
C. Establish an airway and provide oxygen.
D. Apply a sterile dressing to the burn area.
Answer: C. Establish an airway and provide oxygen.
Rationale:
The priority in burn management is to ensure the client’s airway is
patent and to provide oxygenation. Airway management is the first step
to prevent hypoxia and further complications. Other actions like
assessing for infection or applying dressings are important but not as
immediate as ensuring adequate ventilation.
2. A nurse is caring for a client with diabetes mellitus. The client
reports feeling shaky, sweating, and dizzy. What is the nurse's priority
action?
A. Check the client’s blood glucose level.
B. Administer insulin as prescribed.
C. Offer the client a high-protein snack.
D. Notify the healthcare provider.
Answer: A. Check the client’s blood glucose level.
Rationale:
Shakiness, sweating, and dizziness are signs of hypoglycemia. The first
action should be to check the client’s blood glucose to confirm if
hypoglycemia is the cause. If the blood glucose is low, the nurse can
,administer the appropriate treatment, such as a quick source of
glucose.
3. Which of the following nursing interventions is most appropriate for
a client with chronic obstructive pulmonary disease (COPD) during an
acute exacerbation?
A. Encourage the client to cough forcefully.
B. Administer oxygen to maintain oxygen saturation of 92-98%.
C. Place the client in the supine position for comfort.
D. Restrict fluid intake to prevent fluid retention.
Answer: B. Administer oxygen to maintain oxygen saturation of 92-
98%.
Rationale:
In COPD exacerbations, oxygen therapy is crucial to maintain adequate
oxygenation. The goal is to maintain oxygen saturation between 92-
98%. Coughing forcefully and restricting fluids are not recommended
during an acute exacerbation, and the client should not be placed in the
supine position due to the risk of increasing respiratory distress.
4. A nurse is caring for a client who is receiving chemotherapy. The
client’s white blood cell count is 2,000/mm³. Which of the following
actions should the nurse take first?
A. Place the client on contact precautions.
B. Administer the prescribed granulocyte colony-stimulating factor.
C. Encourage the client to avoid crowded places.
D. Prepare the client for a blood transfusion.
Answer: C. Encourage the client to avoid crowded places.
, Rationale:
A low white blood cell count (neutropenia) increases the risk of
infection. The priority is to reduce exposure to infectious agents, such
as advising the client to avoid crowded places. The other actions
(precautions, medications, and transfusions) are also important but
secondary.
5. A nurse is caring for a patient who is post-operative following a
total hip replacement. The nurse notes that the client has severe pain
in the left hip, and the leg appears shortened and externally rotated.
What should the nurse suspect?
A. Hip dislocation
B. Infection
C. Deep vein thrombosis
D. Pulmonary embolism
Answer: A. Hip dislocation
Rationale:
A shortened, externally rotated leg following hip replacement surgery is
a classic sign of hip dislocation. Immediate intervention is necessary to
prevent further injury and complications. The other options may also be
possible but do not typically present with this specific combination of
signs and symptoms.
6. Which of the following is the most important action for the nurse
when caring for a client with an indwelling urinary catheter?
A. Remove the catheter as soon as possible to prevent infection.
B. Clean the catheter insertion site with alcohol.
