1. A nurse is caring for a patient with COPD (Chronic Obstructive
Pulmonary Disease) who is experiencing increased shortness of
breath. Which of the following actions should the nurse take first?
A) Administer a bronchodilator
B) Elevate the head of the bed
C) Obtain a pulse oximeter reading
D) Encourage the patient to use pursed-lip breathing
Answer: C) Obtain a pulse oximeter reading
Rationale: The first step is to assess the patient's oxygenation status
using pulse oximetry. This will provide objective data on the patient's
respiratory function and guide further interventions such as
administering oxygen or bronchodilators.
2. A nurse is caring for a patient with a newly placed tracheostomy.
Which of the following actions should the nurse take to reduce the
risk of infection?
A) Use sterile technique for suctioning
B) Apply hydrogen peroxide to the tracheostomy site
C) Change the tracheostomy tube every 72 hours
D) Clean the site with soap and water daily
Answer: A) Use sterile technique for suctioning
Rationale: Using sterile technique for suctioning helps prevent infection
by minimizing the introduction of pathogens. It is important to clean
the tracheostomy site with sterile saline, not hydrogen peroxide, to
avoid irritation.
,3. A nurse is caring for a client with heart failure. Which of the
following findings is the most important to report to the provider?
A) Bilateral pitting edema in the lower legs
B) Increased weight by 1.5 kg (3.3 lb) in 24 hours
C) Mild shortness of breath on exertion
D) Jugular vein distention when sitting at a 45-degree angle
Answer: B) Increased weight by 1.5 kg (3.3 lb) in 24 hours
Rationale: Rapid weight gain is a significant indicator of fluid retention
and worsening heart failure. The nurse should report this to the
healthcare provider promptly for further assessment and management.
4. A nurse is caring for a patient who is receiving total parenteral
nutrition (TPN). Which of the following is the most important action
to prevent infection?
A) Discard unused TPN after 24 hours
B) Use aseptic technique when changing the dressing
C) Monitor the patient's blood glucose every 4 hours
D) Maintain the TPN at room temperature
Answer: B) Use aseptic technique when changing the dressing
Rationale: Infection control is critical when dealing with TPN because of
the risk of bacterial growth in the IV catheter. Aseptic technique should
be used for dressing changes to reduce the risk of infection.
5. A nurse is caring for a patient with a cast on the right arm. The
nurse notes that the patient's fingers are cool and pale, with
decreased capillary refill. Which of the following actions should the
nurse take first?
, A) Apply ice to the arm
B) Elevate the arm above the level of the heart
C) Check the patient's radial pulse
D) Loosen the cast
Answer: C) Check the patient's radial pulse
Rationale: The nurse should assess circulation first by checking the
pulse. If the pulse is weak or absent, further actions may be necessary,
such as loosening the cast or contacting the healthcare provider.
6. A nurse is caring for a patient with an abdominal wound that has
dehisced. Which of the following actions should the nurse take first?
A) Apply a sterile dressing to the wound
B) Notify the healthcare provider
C) Assess the patient's vital signs
D) Place the patient in a low Fowler’s position
Answer: A) Apply a sterile dressing to the wound
Rationale: The first priority is to protect the wound from infection and
further damage by applying a sterile dressing. Afterward, the nurse
should notify the provider, assess vital signs, and position the patient as
needed.
7. A nurse is caring for a client with diabetes mellitus who is scheduled
for surgery. Which of the following actions is most important before
the procedure?
A) Hold the client’s morning insulin dose
B) Encourage the client to eat a high-protein breakfast
Pulmonary Disease) who is experiencing increased shortness of
breath. Which of the following actions should the nurse take first?
A) Administer a bronchodilator
B) Elevate the head of the bed
C) Obtain a pulse oximeter reading
D) Encourage the patient to use pursed-lip breathing
Answer: C) Obtain a pulse oximeter reading
Rationale: The first step is to assess the patient's oxygenation status
using pulse oximetry. This will provide objective data on the patient's
respiratory function and guide further interventions such as
administering oxygen or bronchodilators.
2. A nurse is caring for a patient with a newly placed tracheostomy.
Which of the following actions should the nurse take to reduce the
risk of infection?
A) Use sterile technique for suctioning
B) Apply hydrogen peroxide to the tracheostomy site
C) Change the tracheostomy tube every 72 hours
D) Clean the site with soap and water daily
Answer: A) Use sterile technique for suctioning
Rationale: Using sterile technique for suctioning helps prevent infection
by minimizing the introduction of pathogens. It is important to clean
the tracheostomy site with sterile saline, not hydrogen peroxide, to
avoid irritation.
,3. A nurse is caring for a client with heart failure. Which of the
following findings is the most important to report to the provider?
A) Bilateral pitting edema in the lower legs
B) Increased weight by 1.5 kg (3.3 lb) in 24 hours
C) Mild shortness of breath on exertion
D) Jugular vein distention when sitting at a 45-degree angle
Answer: B) Increased weight by 1.5 kg (3.3 lb) in 24 hours
Rationale: Rapid weight gain is a significant indicator of fluid retention
and worsening heart failure. The nurse should report this to the
healthcare provider promptly for further assessment and management.
4. A nurse is caring for a patient who is receiving total parenteral
nutrition (TPN). Which of the following is the most important action
to prevent infection?
A) Discard unused TPN after 24 hours
B) Use aseptic technique when changing the dressing
C) Monitor the patient's blood glucose every 4 hours
D) Maintain the TPN at room temperature
Answer: B) Use aseptic technique when changing the dressing
Rationale: Infection control is critical when dealing with TPN because of
the risk of bacterial growth in the IV catheter. Aseptic technique should
be used for dressing changes to reduce the risk of infection.
5. A nurse is caring for a patient with a cast on the right arm. The
nurse notes that the patient's fingers are cool and pale, with
decreased capillary refill. Which of the following actions should the
nurse take first?
, A) Apply ice to the arm
B) Elevate the arm above the level of the heart
C) Check the patient's radial pulse
D) Loosen the cast
Answer: C) Check the patient's radial pulse
Rationale: The nurse should assess circulation first by checking the
pulse. If the pulse is weak or absent, further actions may be necessary,
such as loosening the cast or contacting the healthcare provider.
6. A nurse is caring for a patient with an abdominal wound that has
dehisced. Which of the following actions should the nurse take first?
A) Apply a sterile dressing to the wound
B) Notify the healthcare provider
C) Assess the patient's vital signs
D) Place the patient in a low Fowler’s position
Answer: A) Apply a sterile dressing to the wound
Rationale: The first priority is to protect the wound from infection and
further damage by applying a sterile dressing. Afterward, the nurse
should notify the provider, assess vital signs, and position the patient as
needed.
7. A nurse is caring for a client with diabetes mellitus who is scheduled
for surgery. Which of the following actions is most important before
the procedure?
A) Hold the client’s morning insulin dose
B) Encourage the client to eat a high-protein breakfast
