1. A nurse is caring for a client who is post-operative following a right
knee arthroplasty. The client reports pain 8/10 at the surgical site.
Which of the following interventions should the nurse prioritize?
A) Administer a prescribed opioid analgesic
B) Teach the client about pain management techniques
C) Reposition the client to improve comfort
D) Perform a neurovascular assessment on the affected limb
Answer: D) Perform a neurovascular assessment on the affected limb
Rationale:
The priority action is to perform a neurovascular assessment to ensure
there is no impairment to circulation or nerve function following
surgery. While pain management is important, addressing potential
complications such as compartment syndrome or poor circulation is the
immediate priority in a post-operative client.
2. A nurse is preparing to administer a dose of digoxin to a client with
heart failure. Which of the following actions should the nurse take
before administering the medication?
A) Assess the client's blood pressure
B) Assess the client's heart rate
C) Obtain an electrocardiogram
D) Assess the client's respiratory rate
Answer: B) Assess the client's heart rate
Rationale:
Digoxin is a cardiac glycoside that slows the heart rate. The nurse
should assess the heart rate before administration. If the heart rate is
less than 60 beats per minute, the nurse should withhold the
,medication and contact the provider, as this could be a sign of digoxin
toxicity or bradycardia.
3. A nurse is caring for a client with type 2 diabetes mellitus who is
scheduled for surgery. The client asks if they should take their insulin
on the day of the procedure. Which of the following actions should
the nurse take?
A) Administer the full dose of insulin as usual
B) Administer half the dose of insulin and hold the other half
C) Withhold the insulin and notify the provider
D) Administer the insulin after the surgery is complete
Answer: C) Withhold the insulin and notify the provider
Rationale:
Surgical procedures can cause stress-induced hyperglycemia, and the
provider will adjust the insulin regimen accordingly. The nurse should
withhold insulin and notify the provider to avoid the risk of
hypoglycemia, especially if the client is fasting prior to surgery.
4. A client is receiving a blood transfusion and begins to experience
chills, fever, and back pain. Which of the following actions should the
nurse take first?
A) Increase the rate of the transfusion
B) Stop the transfusion immediately
C) Administer acetaminophen for fever
D) Obtain a urine specimen for analysis
Answer: B) Stop the transfusion immediately
, Rationale:
The client is exhibiting signs of a transfusion reaction, such as fever,
chills, and back pain. The nurse should stop the transfusion immediately
to prevent further complications, such as hemolytic reaction. After
stopping the transfusion, the nurse should assess the client, notify the
provider, and follow the facility's protocol for transfusion reactions.
5. A nurse is caring for a client with a chest tube after a thoracotomy.
The nurse notices that the drainage in the collection chamber is
greater than 100 mL per hour. Which of the following actions should
the nurse take?
A) Increase the suction pressure on the chest tube system
B) Notify the healthcare provider immediately
C) Monitor the client for signs of infection
D) Document the drainage and continue to monitor the client
Answer: B) Notify the healthcare provider immediately
Rationale:
A drainage greater than 100 mL per hour could indicate a potential
complication, such as hemorrhage or active bleeding, which requires
immediate medical attention. The nurse should notify the healthcare
provider to address the possible complication.
6. A nurse is assessing a client who is 12 hours post-appendectomy.
The client’s abdomen is distended, and the nurse notes absent bowel
sounds. Which of the following actions should the nurse take?
A) Administer a dose of laxative as ordered
B) Start an intravenous fluid bolus as ordered
knee arthroplasty. The client reports pain 8/10 at the surgical site.
Which of the following interventions should the nurse prioritize?
A) Administer a prescribed opioid analgesic
B) Teach the client about pain management techniques
C) Reposition the client to improve comfort
D) Perform a neurovascular assessment on the affected limb
Answer: D) Perform a neurovascular assessment on the affected limb
Rationale:
The priority action is to perform a neurovascular assessment to ensure
there is no impairment to circulation or nerve function following
surgery. While pain management is important, addressing potential
complications such as compartment syndrome or poor circulation is the
immediate priority in a post-operative client.
2. A nurse is preparing to administer a dose of digoxin to a client with
heart failure. Which of the following actions should the nurse take
before administering the medication?
A) Assess the client's blood pressure
B) Assess the client's heart rate
C) Obtain an electrocardiogram
D) Assess the client's respiratory rate
Answer: B) Assess the client's heart rate
Rationale:
Digoxin is a cardiac glycoside that slows the heart rate. The nurse
should assess the heart rate before administration. If the heart rate is
less than 60 beats per minute, the nurse should withhold the
,medication and contact the provider, as this could be a sign of digoxin
toxicity or bradycardia.
3. A nurse is caring for a client with type 2 diabetes mellitus who is
scheduled for surgery. The client asks if they should take their insulin
on the day of the procedure. Which of the following actions should
the nurse take?
A) Administer the full dose of insulin as usual
B) Administer half the dose of insulin and hold the other half
C) Withhold the insulin and notify the provider
D) Administer the insulin after the surgery is complete
Answer: C) Withhold the insulin and notify the provider
Rationale:
Surgical procedures can cause stress-induced hyperglycemia, and the
provider will adjust the insulin regimen accordingly. The nurse should
withhold insulin and notify the provider to avoid the risk of
hypoglycemia, especially if the client is fasting prior to surgery.
4. A client is receiving a blood transfusion and begins to experience
chills, fever, and back pain. Which of the following actions should the
nurse take first?
A) Increase the rate of the transfusion
B) Stop the transfusion immediately
C) Administer acetaminophen for fever
D) Obtain a urine specimen for analysis
Answer: B) Stop the transfusion immediately
, Rationale:
The client is exhibiting signs of a transfusion reaction, such as fever,
chills, and back pain. The nurse should stop the transfusion immediately
to prevent further complications, such as hemolytic reaction. After
stopping the transfusion, the nurse should assess the client, notify the
provider, and follow the facility's protocol for transfusion reactions.
5. A nurse is caring for a client with a chest tube after a thoracotomy.
The nurse notices that the drainage in the collection chamber is
greater than 100 mL per hour. Which of the following actions should
the nurse take?
A) Increase the suction pressure on the chest tube system
B) Notify the healthcare provider immediately
C) Monitor the client for signs of infection
D) Document the drainage and continue to monitor the client
Answer: B) Notify the healthcare provider immediately
Rationale:
A drainage greater than 100 mL per hour could indicate a potential
complication, such as hemorrhage or active bleeding, which requires
immediate medical attention. The nurse should notify the healthcare
provider to address the possible complication.
6. A nurse is assessing a client who is 12 hours post-appendectomy.
The client’s abdomen is distended, and the nurse notes absent bowel
sounds. Which of the following actions should the nurse take?
A) Administer a dose of laxative as ordered
B) Start an intravenous fluid bolus as ordered
