1. A nurse is caring for a client who is recovering from surgery. Which
of the following is an expected finding during the first 24 hours after
surgery?
a) Blood pressure of 80/50 mmHg
b) Warm, dry skin
c) Temperature of 38.2°C (100.8°F)
d) Pulse rate of 120 beats per minute
Answer: c) Temperature of 38.2°C (100.8°F)
Rationale: A mild temperature increase during the first 24 hours after
surgery is a normal physiological response to the stress of surgery and
anesthesia. A temperature above 100.4°F (38°C) warrants further
investigation. A low blood pressure (a) and a high pulse rate (d) may
indicate complications, and warm, dry skin (b) is typically expected in
stable conditions but not as an isolated marker post-surgery.
2. The nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). Which of the following interventions is the highest
priority for this client during an acute exacerbation?
a) Administering a bronchodilator
b) Encouraging the client to perform deep breathing exercises
c) Providing high-flow oxygen
d) Restricting fluid intake
Answer: a) Administering a bronchodilator
Rationale: During an acute exacerbation of COPD, the primary goal is to
relieve bronchospasm and improve airway clearance. Administering a
bronchodilator (a) helps open the airways and improves breathing.
High-flow oxygen (c) may worsen CO2 retention in COPD patients and
,should be used cautiously. Encouraging deep breathing (b) and
restricting fluids (d) are not the immediate priorities in exacerbation.
3. A nurse is providing discharge teaching to a client who has had a
myocardial infarction (MI). Which of the following statements by the
client indicates an understanding of the teaching?
a) “I will eat a diet high in salt to help prevent low blood pressure.”
b) “I should avoid taking aspirin unless I have chest pain.”
c) “I can resume driving as soon as I feel up to it.”
d) “I will call my provider if I experience chest pain or shortness of
breath.”
Answer: d) “I will call my provider if I experience chest pain or
shortness of breath.”
Rationale: Clients recovering from an MI should be aware that chest
pain or shortness of breath could indicate a recurrence of symptoms or
complications, and they should contact their healthcare provider
immediately. The other options are incorrect as they involve
inappropriate behaviors that could increase the risk for another MI or
complication.
4. A nurse is assessing a client who has a diagnosis of pneumonia.
Which of the following is a priority finding that the nurse should
report to the healthcare provider?
a) Temperature of 38.0°C (100.4°F)
b) Increased respiratory rate
c) Cyanosis of the lips and nail beds
d) Productive cough with yellow-green sputum
, Answer: c) Cyanosis of the lips and nail beds
Rationale: Cyanosis indicates hypoxia, which is a priority finding in a
client with pneumonia. It suggests that the client is not oxygenating
properly, and this requires immediate intervention. The other findings,
such as fever (a), increased respiratory rate (b), and a productive cough
(d), are common in pneumonia but do not require immediate action like
cyanosis does.
5. A nurse is caring for a client who is receiving chemotherapy and is
at risk for neutropenia. Which of the following actions should the
nurse take?
a) Encourage the client to stay in crowded areas to build immunity
b) Restrict visitors to those who are not ill
c) Provide the client with fresh flowers in the room
d) Teach the client to perform deep breathing exercises
Answer: b) Restrict visitors to those who are not ill
Rationale: Neutropenic clients are at risk for infections, so it is
important to restrict visitors who may be ill and encourage practices to
prevent infection. Fresh flowers (c) should be avoided because they can
harbor bacteria. The client should avoid crowded areas (a) to reduce
the risk of infection. Deep breathing exercises (d) are beneficial for
overall health but are not specific to preventing infection.
6. A nurse is preparing a client for a colonoscopy. Which of the
following actions should the nurse take first?
a) Instruct the client to take a clear liquid diet for 24 hours before the
procedure
of the following is an expected finding during the first 24 hours after
surgery?
a) Blood pressure of 80/50 mmHg
b) Warm, dry skin
c) Temperature of 38.2°C (100.8°F)
d) Pulse rate of 120 beats per minute
Answer: c) Temperature of 38.2°C (100.8°F)
Rationale: A mild temperature increase during the first 24 hours after
surgery is a normal physiological response to the stress of surgery and
anesthesia. A temperature above 100.4°F (38°C) warrants further
investigation. A low blood pressure (a) and a high pulse rate (d) may
indicate complications, and warm, dry skin (b) is typically expected in
stable conditions but not as an isolated marker post-surgery.
2. The nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). Which of the following interventions is the highest
priority for this client during an acute exacerbation?
a) Administering a bronchodilator
b) Encouraging the client to perform deep breathing exercises
c) Providing high-flow oxygen
d) Restricting fluid intake
Answer: a) Administering a bronchodilator
Rationale: During an acute exacerbation of COPD, the primary goal is to
relieve bronchospasm and improve airway clearance. Administering a
bronchodilator (a) helps open the airways and improves breathing.
High-flow oxygen (c) may worsen CO2 retention in COPD patients and
,should be used cautiously. Encouraging deep breathing (b) and
restricting fluids (d) are not the immediate priorities in exacerbation.
3. A nurse is providing discharge teaching to a client who has had a
myocardial infarction (MI). Which of the following statements by the
client indicates an understanding of the teaching?
a) “I will eat a diet high in salt to help prevent low blood pressure.”
b) “I should avoid taking aspirin unless I have chest pain.”
c) “I can resume driving as soon as I feel up to it.”
d) “I will call my provider if I experience chest pain or shortness of
breath.”
Answer: d) “I will call my provider if I experience chest pain or
shortness of breath.”
Rationale: Clients recovering from an MI should be aware that chest
pain or shortness of breath could indicate a recurrence of symptoms or
complications, and they should contact their healthcare provider
immediately. The other options are incorrect as they involve
inappropriate behaviors that could increase the risk for another MI or
complication.
4. A nurse is assessing a client who has a diagnosis of pneumonia.
Which of the following is a priority finding that the nurse should
report to the healthcare provider?
a) Temperature of 38.0°C (100.4°F)
b) Increased respiratory rate
c) Cyanosis of the lips and nail beds
d) Productive cough with yellow-green sputum
, Answer: c) Cyanosis of the lips and nail beds
Rationale: Cyanosis indicates hypoxia, which is a priority finding in a
client with pneumonia. It suggests that the client is not oxygenating
properly, and this requires immediate intervention. The other findings,
such as fever (a), increased respiratory rate (b), and a productive cough
(d), are common in pneumonia but do not require immediate action like
cyanosis does.
5. A nurse is caring for a client who is receiving chemotherapy and is
at risk for neutropenia. Which of the following actions should the
nurse take?
a) Encourage the client to stay in crowded areas to build immunity
b) Restrict visitors to those who are not ill
c) Provide the client with fresh flowers in the room
d) Teach the client to perform deep breathing exercises
Answer: b) Restrict visitors to those who are not ill
Rationale: Neutropenic clients are at risk for infections, so it is
important to restrict visitors who may be ill and encourage practices to
prevent infection. Fresh flowers (c) should be avoided because they can
harbor bacteria. The client should avoid crowded areas (a) to reduce
the risk of infection. Deep breathing exercises (d) are beneficial for
overall health but are not specific to preventing infection.
6. A nurse is preparing a client for a colonoscopy. Which of the
following actions should the nurse take first?
a) Instruct the client to take a clear liquid diet for 24 hours before the
procedure
