1. A nurse is caring for a postoperative client following a
cholecystectomy. The client begins to report severe pain in the upper
right quadrant. What is the priority nursing action?
A) Administer pain medication as prescribed.
B) Obtain a blood pressure reading.
C) Assess for signs of internal bleeding.
D) Place the client in a low Fowler’s position.
Answer: C) Assess for signs of internal bleeding.
Rationale: Severe pain in the upper right quadrant after a
cholecystectomy could indicate internal bleeding or a bile leak. The
nurse must first assess the client for signs of these complications before
administering pain medication or other interventions.
2. A nurse is assessing a client with heart failure. Which of the
following findings indicates the client is experiencing fluid overload?
A) Increased respiratory rate and crackles in the lungs
B) Decreased blood pressure and increased heart rate
C) Decreased temperature and cool extremities
D) Increased urination and weight loss
Answer: A) Increased respiratory rate and crackles in the lungs.
Rationale: Fluid overload in heart failure often leads to pulmonary
edema, which is evidenced by increased respiratory rate and crackles
(rales) in the lungs. This indicates that the client’s heart is unable to
effectively pump blood, causing fluid to accumulate in the lungs.
,3. A client is receiving warfarin therapy for atrial fibrillation. Which
laboratory test should the nurse monitor to assess the effectiveness of
the medication?
A) Hemoglobin and hematocrit
B) Prothrombin time (PT) and International Normalized Ratio (INR)
C) Platelet count
D) Activated partial thromboplastin time (aPTT)
Answer: B) Prothrombin time (PT) and International Normalized Ratio
(INR).
Rationale: Warfarin therapy is monitored by measuring the PT and INR
to ensure therapeutic anticoagulation. These values help guide dosage
adjustments to prevent bleeding complications.
4. A nurse is caring for a client with a newly inserted central venous
catheter (CVC). Which of the following is the priority nursing action to
prevent infection?
A) Administer prescribed antibiotics.
B) Monitor vital signs every 4 hours.
C) Maintain sterile technique during dressing changes.
D) Assess the site for redness and swelling.
Answer: C) Maintain sterile technique during dressing changes.
Rationale: The most important intervention to prevent infection in a
client with a central venous catheter is to maintain strict sterile
technique during dressing changes to avoid introducing pathogens at
the catheter insertion site.
, 5. A nurse is caring for a client who is receiving hemodialysis. The
client develops hypotension. Which of the following interventions
should the nurse implement first?
A) Increase the dialysis flow rate.
B) Administer intravenous fluids as prescribed.
C) Slow the rate of dialysis.
D) Administer antihypertensive medications.
Answer: C) Slow the rate of dialysis.
Rationale: Hypotension during hemodialysis is often related to the
rapid removal of fluid. The priority intervention is to slow the rate of
dialysis to prevent further hypotension and related complications.
6. A nurse is providing discharge teaching to a client who has been
prescribed insulin for diabetes mellitus. Which of the following
statements by the client indicates the need for further teaching?
A) “I will rotate the injection sites to prevent lipodystrophy.”
B) “I should store my insulin in the refrigerator until it is opened.”
C) “I will only use a syringe that is specifically marked for insulin.”
D) “I will increase my insulin dose when I feel stressed or ill.”
Answer: D) “I will increase my insulin dose when I feel stressed or ill.”
Rationale: Illness or stress can increase blood glucose levels, but the
insulin dose should only be adjusted according to a healthcare
provider's recommendation. The client should not independently alter
the insulin dose without consultation.
cholecystectomy. The client begins to report severe pain in the upper
right quadrant. What is the priority nursing action?
A) Administer pain medication as prescribed.
B) Obtain a blood pressure reading.
C) Assess for signs of internal bleeding.
D) Place the client in a low Fowler’s position.
Answer: C) Assess for signs of internal bleeding.
Rationale: Severe pain in the upper right quadrant after a
cholecystectomy could indicate internal bleeding or a bile leak. The
nurse must first assess the client for signs of these complications before
administering pain medication or other interventions.
2. A nurse is assessing a client with heart failure. Which of the
following findings indicates the client is experiencing fluid overload?
A) Increased respiratory rate and crackles in the lungs
B) Decreased blood pressure and increased heart rate
C) Decreased temperature and cool extremities
D) Increased urination and weight loss
Answer: A) Increased respiratory rate and crackles in the lungs.
Rationale: Fluid overload in heart failure often leads to pulmonary
edema, which is evidenced by increased respiratory rate and crackles
(rales) in the lungs. This indicates that the client’s heart is unable to
effectively pump blood, causing fluid to accumulate in the lungs.
,3. A client is receiving warfarin therapy for atrial fibrillation. Which
laboratory test should the nurse monitor to assess the effectiveness of
the medication?
A) Hemoglobin and hematocrit
B) Prothrombin time (PT) and International Normalized Ratio (INR)
C) Platelet count
D) Activated partial thromboplastin time (aPTT)
Answer: B) Prothrombin time (PT) and International Normalized Ratio
(INR).
Rationale: Warfarin therapy is monitored by measuring the PT and INR
to ensure therapeutic anticoagulation. These values help guide dosage
adjustments to prevent bleeding complications.
4. A nurse is caring for a client with a newly inserted central venous
catheter (CVC). Which of the following is the priority nursing action to
prevent infection?
A) Administer prescribed antibiotics.
B) Monitor vital signs every 4 hours.
C) Maintain sterile technique during dressing changes.
D) Assess the site for redness and swelling.
Answer: C) Maintain sterile technique during dressing changes.
Rationale: The most important intervention to prevent infection in a
client with a central venous catheter is to maintain strict sterile
technique during dressing changes to avoid introducing pathogens at
the catheter insertion site.
, 5. A nurse is caring for a client who is receiving hemodialysis. The
client develops hypotension. Which of the following interventions
should the nurse implement first?
A) Increase the dialysis flow rate.
B) Administer intravenous fluids as prescribed.
C) Slow the rate of dialysis.
D) Administer antihypertensive medications.
Answer: C) Slow the rate of dialysis.
Rationale: Hypotension during hemodialysis is often related to the
rapid removal of fluid. The priority intervention is to slow the rate of
dialysis to prevent further hypotension and related complications.
6. A nurse is providing discharge teaching to a client who has been
prescribed insulin for diabetes mellitus. Which of the following
statements by the client indicates the need for further teaching?
A) “I will rotate the injection sites to prevent lipodystrophy.”
B) “I should store my insulin in the refrigerator until it is opened.”
C) “I will only use a syringe that is specifically marked for insulin.”
D) “I will increase my insulin dose when I feel stressed or ill.”
Answer: D) “I will increase my insulin dose when I feel stressed or ill.”
Rationale: Illness or stress can increase blood glucose levels, but the
insulin dose should only be adjusted according to a healthcare
provider's recommendation. The client should not independently alter
the insulin dose without consultation.
