Question 1:
A nurse is caring for a client who is post-operative following a
cholecystectomy. The nurse should monitor for which of the following
complications? A) Hypokalemia
B) Pneumonia
C) Bile leakage
D) Pericarditis
Answer: C) Bile leakage
Rationale: After a cholecystectomy, bile leakage can occur, leading to
peritonitis or infection. It's essential to monitor the site for bile leakage.
Hypokalemia and pneumonia are also concerns, but they are not as
specific to this procedure as bile leakage.
Question 2:
A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). Which of the following should the nurse prioritize
when developing a care plan? A) Encourage bed rest to reduce energy
expenditure
B) Promote fluid restriction to prevent fluid overload
C) Instruct the client to perform pursed-lip breathing
D) Administer high-flow oxygen therapy
Answer: C) Instruct the client to perform pursed-lip breathing
Rationale: Pursed-lip breathing helps reduce airway resistance and
promotes the elimination of carbon dioxide. This technique is an
important part of managing COPD. Bed rest, fluid restriction, and high-
flow oxygen are not generally recommended unless there are specific
indications.
,Question 3:
A nurse is preparing to administer an intravenous (IV) medication to a
client who has a history of a severe allergic reaction to penicillin.
Which of the following is the most appropriate action? A) Administer
the medication as prescribed
B) Ask the provider for an alternative medication
C) Proceed with the IV medication but decrease the dosage
D) Monitor the client closely for 30 minutes post-administration
Answer: B) Ask the provider for an alternative medication
Rationale: If a client has a severe allergic reaction to penicillin,
administering any related antibiotics or medications is contraindicated.
The nurse should contact the provider to inquire about an alternative
medication. Monitoring alone is insufficient without addressing the root
cause.
Question 4:
A client with heart failure is prescribed a loop diuretic. The nurse
should monitor for which of the following electrolyte imbalances? A)
Hyperkalemia
B) Hypercalcemia
C) Hypomagnesemia
D) Hypokalemia
Answer: D) Hypokalemia
Rationale: Loop diuretics, like furosemide, can cause the kidneys to
excrete potassium, leading to hypokalemia. Electrolyte levels should be
regularly monitored, and potassium supplementation may be needed.
, Question 5:
A nurse is caring for a client with a diagnosis of pneumonia. The nurse
should assess for which of the following as an early sign of respiratory
distress? A) Bradypnea
B) Tachypnea
C) Cyanosis
D) Diaphoresis
Answer: B) Tachypnea
Rationale: Tachypnea, or rapid breathing, is an early sign of respiratory
distress and is often seen in clients with pneumonia. It indicates the
body’s attempt to increase oxygen intake. Cyanosis, bradypnea, and
diaphoresis are later signs.
Question 6:
A client is admitted to the hospital with acute pancreatitis. The nurse
should monitor the client for which of the following complications? A)
Hypoglycemia
B) Hypercalcemia
C) Hemorrhagic shock
D) Renal failure
Answer: C) Hemorrhagic shock
Rationale: Acute pancreatitis can lead to hemorrhagic shock, especially
if the inflammation or infection causes bleeding in the pancreas.
Hypoglycemia and hypercalcemia are not typical complications of acute
pancreatitis, while renal failure is a possible secondary complication but
not as common as hemorrhagic shock.
A nurse is caring for a client who is post-operative following a
cholecystectomy. The nurse should monitor for which of the following
complications? A) Hypokalemia
B) Pneumonia
C) Bile leakage
D) Pericarditis
Answer: C) Bile leakage
Rationale: After a cholecystectomy, bile leakage can occur, leading to
peritonitis or infection. It's essential to monitor the site for bile leakage.
Hypokalemia and pneumonia are also concerns, but they are not as
specific to this procedure as bile leakage.
Question 2:
A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). Which of the following should the nurse prioritize
when developing a care plan? A) Encourage bed rest to reduce energy
expenditure
B) Promote fluid restriction to prevent fluid overload
C) Instruct the client to perform pursed-lip breathing
D) Administer high-flow oxygen therapy
Answer: C) Instruct the client to perform pursed-lip breathing
Rationale: Pursed-lip breathing helps reduce airway resistance and
promotes the elimination of carbon dioxide. This technique is an
important part of managing COPD. Bed rest, fluid restriction, and high-
flow oxygen are not generally recommended unless there are specific
indications.
,Question 3:
A nurse is preparing to administer an intravenous (IV) medication to a
client who has a history of a severe allergic reaction to penicillin.
Which of the following is the most appropriate action? A) Administer
the medication as prescribed
B) Ask the provider for an alternative medication
C) Proceed with the IV medication but decrease the dosage
D) Monitor the client closely for 30 minutes post-administration
Answer: B) Ask the provider for an alternative medication
Rationale: If a client has a severe allergic reaction to penicillin,
administering any related antibiotics or medications is contraindicated.
The nurse should contact the provider to inquire about an alternative
medication. Monitoring alone is insufficient without addressing the root
cause.
Question 4:
A client with heart failure is prescribed a loop diuretic. The nurse
should monitor for which of the following electrolyte imbalances? A)
Hyperkalemia
B) Hypercalcemia
C) Hypomagnesemia
D) Hypokalemia
Answer: D) Hypokalemia
Rationale: Loop diuretics, like furosemide, can cause the kidneys to
excrete potassium, leading to hypokalemia. Electrolyte levels should be
regularly monitored, and potassium supplementation may be needed.
, Question 5:
A nurse is caring for a client with a diagnosis of pneumonia. The nurse
should assess for which of the following as an early sign of respiratory
distress? A) Bradypnea
B) Tachypnea
C) Cyanosis
D) Diaphoresis
Answer: B) Tachypnea
Rationale: Tachypnea, or rapid breathing, is an early sign of respiratory
distress and is often seen in clients with pneumonia. It indicates the
body’s attempt to increase oxygen intake. Cyanosis, bradypnea, and
diaphoresis are later signs.
Question 6:
A client is admitted to the hospital with acute pancreatitis. The nurse
should monitor the client for which of the following complications? A)
Hypoglycemia
B) Hypercalcemia
C) Hemorrhagic shock
D) Renal failure
Answer: C) Hemorrhagic shock
Rationale: Acute pancreatitis can lead to hemorrhagic shock, especially
if the inflammation or infection causes bleeding in the pancreas.
Hypoglycemia and hypercalcemia are not typical complications of acute
pancreatitis, while renal failure is a possible secondary complication but
not as common as hemorrhagic shock.
