1. A nurse is caring for a patient with a new diagnosis of hypertension.
Which of the following actions should the nurse take first?
A) Teach the patient about dietary modifications
B) Encourage the patient to monitor blood pressure at home
C) Initiate the prescribed antihypertensive medication
D) Assess the patient's understanding of the diagnosis
Answer: D) Assess the patient's understanding of the diagnosis
Rationale: The first step in care for a new diagnosis is to assess the
patient's understanding. This allows the nurse to identify any gaps in
knowledge and provide education. The other actions, while important,
should follow after an assessment of the patient's understanding.
2. A nurse is caring for a postoperative patient who is at risk for deep
vein thrombosis (DVT). Which of the following interventions is the
most effective for preventing DVT?
A) Elevating the legs above the heart
B) Applying elastic stockings
C) Encouraging early ambulation
D) Administering anticoagulants
Answer: C) Encouraging early ambulation
Rationale: Early ambulation is the most effective intervention for
preventing DVT. It promotes circulation and reduces the risk of clot
formation. While the other options also help prevent DVT, they are
secondary to early ambulation.
,3. A nurse is providing care for a patient with chronic obstructive
pulmonary disease (COPD). Which of the following findings requires
immediate action?
A) Oxygen saturation of 90%
B) Productive cough with yellow sputum
C) Shortness of breath with exertion
D) Increased wheezing and use of accessory muscles
Answer: D) Increased wheezing and use of accessory muscles
Rationale: Increased wheezing and the use of accessory muscles
indicate respiratory distress, which requires immediate intervention.
The other findings are common in COPD but do not indicate an
immediate emergency.
4. A nurse is teaching a patient about managing type 2 diabetes.
Which statement by the patient indicates the need for further
teaching?
A) "I will check my blood glucose levels regularly."
B) "I should follow a low-sodium diet to help manage my blood
pressure."
C) "I can stop taking my insulin once my blood glucose levels are within
range."
D) "I should exercise regularly to help control my blood sugar."
Answer: C) "I can stop taking my insulin once my blood glucose levels
are within range."
Rationale: Insulin therapy is a lifelong management for many patients
with type 2 diabetes. The patient should not stop taking insulin without
, consulting a healthcare provider, even if blood glucose levels are within
range.
5. A nurse is preparing a patient for a lumbar puncture. Which of the
following actions is the nurse's priority before the procedure?
A) Explain the procedure to the patient
B) Verify informed consent is signed
C) Administer a sedative as prescribed
D) Ensure the patient is in a lateral recumbent position
Answer: B) Verify informed consent is signed
Rationale: Ensuring informed consent is signed is the priority, as this is a
legal requirement before the procedure. The other actions are also
important but follow after verifying consent.
6. A nurse is caring for a patient with an indwelling urinary catheter.
Which of the following is the most important intervention to reduce
the risk of a urinary tract infection (UTI)?
A) Ensure the catheter is secured to prevent tugging
B) Clean the catheter insertion site with soap and water daily
C) Maintain a closed catheter system
D) Encourage the patient to increase fluid intake
Answer: C) Maintain a closed catheter system
Rationale: Maintaining a closed catheter system is the most effective
intervention to prevent UTIs. This reduces the risk of bacterial
contamination. Other measures, such as increased fluid intake, are
important but secondary to keeping the catheter system intact.
Which of the following actions should the nurse take first?
A) Teach the patient about dietary modifications
B) Encourage the patient to monitor blood pressure at home
C) Initiate the prescribed antihypertensive medication
D) Assess the patient's understanding of the diagnosis
Answer: D) Assess the patient's understanding of the diagnosis
Rationale: The first step in care for a new diagnosis is to assess the
patient's understanding. This allows the nurse to identify any gaps in
knowledge and provide education. The other actions, while important,
should follow after an assessment of the patient's understanding.
2. A nurse is caring for a postoperative patient who is at risk for deep
vein thrombosis (DVT). Which of the following interventions is the
most effective for preventing DVT?
A) Elevating the legs above the heart
B) Applying elastic stockings
C) Encouraging early ambulation
D) Administering anticoagulants
Answer: C) Encouraging early ambulation
Rationale: Early ambulation is the most effective intervention for
preventing DVT. It promotes circulation and reduces the risk of clot
formation. While the other options also help prevent DVT, they are
secondary to early ambulation.
,3. A nurse is providing care for a patient with chronic obstructive
pulmonary disease (COPD). Which of the following findings requires
immediate action?
A) Oxygen saturation of 90%
B) Productive cough with yellow sputum
C) Shortness of breath with exertion
D) Increased wheezing and use of accessory muscles
Answer: D) Increased wheezing and use of accessory muscles
Rationale: Increased wheezing and the use of accessory muscles
indicate respiratory distress, which requires immediate intervention.
The other findings are common in COPD but do not indicate an
immediate emergency.
4. A nurse is teaching a patient about managing type 2 diabetes.
Which statement by the patient indicates the need for further
teaching?
A) "I will check my blood glucose levels regularly."
B) "I should follow a low-sodium diet to help manage my blood
pressure."
C) "I can stop taking my insulin once my blood glucose levels are within
range."
D) "I should exercise regularly to help control my blood sugar."
Answer: C) "I can stop taking my insulin once my blood glucose levels
are within range."
Rationale: Insulin therapy is a lifelong management for many patients
with type 2 diabetes. The patient should not stop taking insulin without
, consulting a healthcare provider, even if blood glucose levels are within
range.
5. A nurse is preparing a patient for a lumbar puncture. Which of the
following actions is the nurse's priority before the procedure?
A) Explain the procedure to the patient
B) Verify informed consent is signed
C) Administer a sedative as prescribed
D) Ensure the patient is in a lateral recumbent position
Answer: B) Verify informed consent is signed
Rationale: Ensuring informed consent is signed is the priority, as this is a
legal requirement before the procedure. The other actions are also
important but follow after verifying consent.
6. A nurse is caring for a patient with an indwelling urinary catheter.
Which of the following is the most important intervention to reduce
the risk of a urinary tract infection (UTI)?
A) Ensure the catheter is secured to prevent tugging
B) Clean the catheter insertion site with soap and water daily
C) Maintain a closed catheter system
D) Encourage the patient to increase fluid intake
Answer: C) Maintain a closed catheter system
Rationale: Maintaining a closed catheter system is the most effective
intervention to prevent UTIs. This reduces the risk of bacterial
contamination. Other measures, such as increased fluid intake, are
important but secondary to keeping the catheter system intact.
