1. Which of the following is the most important intervention for a
nurse caring for a postoperative patient to prevent complications?
A) Administering pain medications as prescribed
B) Encouraging deep breathing and coughing exercises
C) Keeping the patient on bed rest for 24 hours
D) Restricting fluid intake to prevent edema
Answer: B) Encouraging deep breathing and coughing exercises
Rationale: Deep breathing and coughing exercises help prevent
respiratory complications like pneumonia and atelectasis, which are
common after surgery. These exercises help clear secretions and
improve lung expansion.
2. A patient with a history of hypertension is prescribed a diuretic.
What is the nurse’s priority when teaching this patient?
A) Monitor for signs of dehydration
B) Increase fluid intake to avoid dehydration
C) Avoid high-potassium foods
D) Take the medication on an empty stomach for better absorption
Answer: A) Monitor for signs of dehydration
Rationale: Diuretics increase urine production, which can lead to
dehydration and electrolyte imbalances, especially in patients with a
history of hypertension. It’s important to monitor for symptoms of
dehydration (e.g., dizziness, dry mouth, low blood pressure).
3. A nurse is caring for a patient receiving IV morphine for
postoperative pain. Which of the following side effects should the
nurse monitor for most closely?
,A) Constipation
B) Tachycardia
C) Hypertension
D) Hypothermia
Answer: A) Constipation
Rationale: Opioid medications like morphine commonly cause
constipation. The nurse should monitor for this side effect and provide
interventions to prevent or treat it (e.g., stool softeners, adequate fluid
intake).
4. A patient is admitted with a diagnosis of acute pancreatitis. The
nurse expects to observe which of the following signs?
A) Elevated blood glucose levels
B) Hypotension
C) Vomiting and abdominal pain
D) Increased serum albumin levels
Answer: C) Vomiting and abdominal pain
Rationale: Acute pancreatitis often presents with severe abdominal
pain and vomiting due to inflammation of the pancreas. Elevated blood
glucose levels may also occur, but vomiting and pain are more common
presenting symptoms.
5. Which of the following is a priority intervention for a patient with a
chest tube after thoracic surgery?
A) Monitor the chest tube drainage for amount and characteristics
B) Position the patient in a left lateral position
, C) Encourage coughing and deep breathing exercises
D) Clamp the chest tube periodically to assess for leaks
Answer: A) Monitor the chest tube drainage for amount and
characteristics
Rationale: Monitoring the chest tube drainage is critical to assess for
any complications such as hemorrhage or pneumothorax. The nurse
should assess for changes in the drainage amount and type (e.g.,
serous, sanguineous, or purulent).
6. A nurse is caring for a patient with a urinary catheter. Which action
is essential to prevent a catheter-associated urinary tract infection
(CAUTI)?
A) Irrigate the catheter daily with sterile water
B) Change the catheter and drainage bag every 48 hours
C) Ensure the catheter is secured to the patient’s thigh
D) Use antiseptic wipes on the catheter insertion site every hour
Answer: C) Ensure the catheter is secured to the patient’s thigh
Rationale: Securing the catheter to the patient’s thigh reduces the risk
of accidental pulling or displacement, which can introduce bacteria into
the urinary tract. It also helps prevent pressure on the catheter, which
can cause trauma to the urethra.
7. Which of the following is the best initial response for a nurse when
a patient develops a sudden onset of shortness of breath and chest
pain?
A) Administer oxygen and call the healthcare provider
B) Have the patient lie down and monitor vital signs
nurse caring for a postoperative patient to prevent complications?
A) Administering pain medications as prescribed
B) Encouraging deep breathing and coughing exercises
C) Keeping the patient on bed rest for 24 hours
D) Restricting fluid intake to prevent edema
Answer: B) Encouraging deep breathing and coughing exercises
Rationale: Deep breathing and coughing exercises help prevent
respiratory complications like pneumonia and atelectasis, which are
common after surgery. These exercises help clear secretions and
improve lung expansion.
2. A patient with a history of hypertension is prescribed a diuretic.
What is the nurse’s priority when teaching this patient?
A) Monitor for signs of dehydration
B) Increase fluid intake to avoid dehydration
C) Avoid high-potassium foods
D) Take the medication on an empty stomach for better absorption
Answer: A) Monitor for signs of dehydration
Rationale: Diuretics increase urine production, which can lead to
dehydration and electrolyte imbalances, especially in patients with a
history of hypertension. It’s important to monitor for symptoms of
dehydration (e.g., dizziness, dry mouth, low blood pressure).
3. A nurse is caring for a patient receiving IV morphine for
postoperative pain. Which of the following side effects should the
nurse monitor for most closely?
,A) Constipation
B) Tachycardia
C) Hypertension
D) Hypothermia
Answer: A) Constipation
Rationale: Opioid medications like morphine commonly cause
constipation. The nurse should monitor for this side effect and provide
interventions to prevent or treat it (e.g., stool softeners, adequate fluid
intake).
4. A patient is admitted with a diagnosis of acute pancreatitis. The
nurse expects to observe which of the following signs?
A) Elevated blood glucose levels
B) Hypotension
C) Vomiting and abdominal pain
D) Increased serum albumin levels
Answer: C) Vomiting and abdominal pain
Rationale: Acute pancreatitis often presents with severe abdominal
pain and vomiting due to inflammation of the pancreas. Elevated blood
glucose levels may also occur, but vomiting and pain are more common
presenting symptoms.
5. Which of the following is a priority intervention for a patient with a
chest tube after thoracic surgery?
A) Monitor the chest tube drainage for amount and characteristics
B) Position the patient in a left lateral position
, C) Encourage coughing and deep breathing exercises
D) Clamp the chest tube periodically to assess for leaks
Answer: A) Monitor the chest tube drainage for amount and
characteristics
Rationale: Monitoring the chest tube drainage is critical to assess for
any complications such as hemorrhage or pneumothorax. The nurse
should assess for changes in the drainage amount and type (e.g.,
serous, sanguineous, or purulent).
6. A nurse is caring for a patient with a urinary catheter. Which action
is essential to prevent a catheter-associated urinary tract infection
(CAUTI)?
A) Irrigate the catheter daily with sterile water
B) Change the catheter and drainage bag every 48 hours
C) Ensure the catheter is secured to the patient’s thigh
D) Use antiseptic wipes on the catheter insertion site every hour
Answer: C) Ensure the catheter is secured to the patient’s thigh
Rationale: Securing the catheter to the patient’s thigh reduces the risk
of accidental pulling or displacement, which can introduce bacteria into
the urinary tract. It also helps prevent pressure on the catheter, which
can cause trauma to the urethra.
7. Which of the following is the best initial response for a nurse when
a patient develops a sudden onset of shortness of breath and chest
pain?
A) Administer oxygen and call the healthcare provider
B) Have the patient lie down and monitor vital signs
