1. A nurse is caring for a patient who is recovering from a laparotomy.
The patient is at risk for postoperative complications. Which of the
following interventions should the nurse prioritize to prevent
atelectasis?
A) Encourage deep breathing and coughing
B) Administer opioids as prescribed
C) Position the patient flat in bed
D) Provide a high-sodium diet
Answer: A) Encourage deep breathing and coughing
Rationale: Deep breathing and coughing help prevent atelectasis by
promoting lung expansion and clearing secretions. Positioning the
patient in a semi-Fowler’s position and encouraging activity are also
helpful, but deep breathing and coughing are the priority interventions
to prevent atelectasis.
2. A patient with heart failure has been prescribed furosemide (Lasix).
Which of the following laboratory results should the nurse review
before administering this medication?
A) Serum potassium
B) Blood glucose
C) Serum calcium
D) Hemoglobin level
Answer: A) Serum potassium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia
(low potassium levels). The nurse should review the serum potassium
levels before administering this medication to ensure the levels are
within the normal range to avoid complications like arrhythmias.
,3. A patient is being prepared for a colonoscopy. The nurse provides
education on the procedure and asks the patient to drink a bowel
prep solution. What is the nurse’s primary concern after the
administration of the bowel prep?
A) Dehydration
B) Abdominal distention
C) Hypertension
D) Respiratory distress
Answer: A) Dehydration
Rationale: The bowel prep solution induces diarrhea to clear the
intestines for the procedure, leading to fluid loss. Dehydration is a
common concern, and the nurse should monitor the patient's hydration
status and provide adequate fluids to prevent it.
4. A nurse is caring for a patient who has just undergone a
cholecystectomy. Which of the following interventions is most
important to help prevent respiratory complications?
A) Administering analgesics as prescribed
B) Encouraging the use of an incentive spirometer
C) Promoting ambulation 2 hours after surgery
D) Restricting fluid intake
Answer: B) Encouraging the use of an incentive spirometer
Rationale: After surgery, it is important to encourage deep breathing to
prevent atelectasis and pneumonia. The use of an incentive spirometer
helps the patient to take deep breaths and expand the lungs fully,
promoting oxygenation and reducing respiratory complications.
, 5. A nurse is caring for a patient who has just been started on warfarin
therapy. Which of the following lab values should the nurse monitor
to assess the effectiveness of the medication?
A) Prothrombin time (PT) and International Normalized Ratio (INR)
B) Hemoglobin and hematocrit
C) Serum creatinine and blood urea nitrogen (BUN)
D) Liver function tests
Answer: A) Prothrombin time (PT) and International Normalized Ratio
(INR)
Rationale: Warfarin is an anticoagulant, and the PT and INR are
monitored to assess its effectiveness in preventing clot formation. The
INR should be kept within a therapeutic range to reduce the risk of
bleeding or clot formation.
6. A patient with a history of hypertension is prescribed an
angiotensin-converting enzyme (ACE) inhibitor. Which of the following
is the most important assessment before administering the
medication?
A) Respiratory rate
B) Blood pressure
C) Blood glucose level
D) Liver enzymes
Answer: B) Blood pressure
Rationale: ACE inhibitors lower blood pressure by inhibiting the
conversion of angiotensin I to angiotensin II. The nurse should assess
the patient’s blood pressure before administration to ensure it is not
too low, as this could lead to hypotension.
The patient is at risk for postoperative complications. Which of the
following interventions should the nurse prioritize to prevent
atelectasis?
A) Encourage deep breathing and coughing
B) Administer opioids as prescribed
C) Position the patient flat in bed
D) Provide a high-sodium diet
Answer: A) Encourage deep breathing and coughing
Rationale: Deep breathing and coughing help prevent atelectasis by
promoting lung expansion and clearing secretions. Positioning the
patient in a semi-Fowler’s position and encouraging activity are also
helpful, but deep breathing and coughing are the priority interventions
to prevent atelectasis.
2. A patient with heart failure has been prescribed furosemide (Lasix).
Which of the following laboratory results should the nurse review
before administering this medication?
A) Serum potassium
B) Blood glucose
C) Serum calcium
D) Hemoglobin level
Answer: A) Serum potassium
Rationale: Furosemide is a loop diuretic that can cause hypokalemia
(low potassium levels). The nurse should review the serum potassium
levels before administering this medication to ensure the levels are
within the normal range to avoid complications like arrhythmias.
,3. A patient is being prepared for a colonoscopy. The nurse provides
education on the procedure and asks the patient to drink a bowel
prep solution. What is the nurse’s primary concern after the
administration of the bowel prep?
A) Dehydration
B) Abdominal distention
C) Hypertension
D) Respiratory distress
Answer: A) Dehydration
Rationale: The bowel prep solution induces diarrhea to clear the
intestines for the procedure, leading to fluid loss. Dehydration is a
common concern, and the nurse should monitor the patient's hydration
status and provide adequate fluids to prevent it.
4. A nurse is caring for a patient who has just undergone a
cholecystectomy. Which of the following interventions is most
important to help prevent respiratory complications?
A) Administering analgesics as prescribed
B) Encouraging the use of an incentive spirometer
C) Promoting ambulation 2 hours after surgery
D) Restricting fluid intake
Answer: B) Encouraging the use of an incentive spirometer
Rationale: After surgery, it is important to encourage deep breathing to
prevent atelectasis and pneumonia. The use of an incentive spirometer
helps the patient to take deep breaths and expand the lungs fully,
promoting oxygenation and reducing respiratory complications.
, 5. A nurse is caring for a patient who has just been started on warfarin
therapy. Which of the following lab values should the nurse monitor
to assess the effectiveness of the medication?
A) Prothrombin time (PT) and International Normalized Ratio (INR)
B) Hemoglobin and hematocrit
C) Serum creatinine and blood urea nitrogen (BUN)
D) Liver function tests
Answer: A) Prothrombin time (PT) and International Normalized Ratio
(INR)
Rationale: Warfarin is an anticoagulant, and the PT and INR are
monitored to assess its effectiveness in preventing clot formation. The
INR should be kept within a therapeutic range to reduce the risk of
bleeding or clot formation.
6. A patient with a history of hypertension is prescribed an
angiotensin-converting enzyme (ACE) inhibitor. Which of the following
is the most important assessment before administering the
medication?
A) Respiratory rate
B) Blood pressure
C) Blood glucose level
D) Liver enzymes
Answer: B) Blood pressure
Rationale: ACE inhibitors lower blood pressure by inhibiting the
conversion of angiotensin I to angiotensin II. The nurse should assess
the patient’s blood pressure before administration to ensure it is not
too low, as this could lead to hypotension.
