1. A nurse is caring for a patient who is receiving a blood transfusion
and starts to develop chills and fever. What should the nurse do first?
a) Notify the healthcare provider
b) Stop the transfusion
c) Administer antipyretic medication
d) Check the patient’s vital signs
Answer: b) Stop the transfusion
Rationale: The first priority when a transfusion reaction occurs (e.g.,
chills and fever) is to stop the transfusion immediately to prevent
further complications. After stopping the transfusion, the nurse should
notify the healthcare provider and follow protocol for managing the
transfusion reaction.
2. A nurse is caring for a patient post-appendectomy. The patient is
having difficulty passing gas. What is the most appropriate action for
the nurse to take?
a) Increase oral fluid intake
b) Encourage deep breathing and ambulation
c) Administer a stool softener
d) Insert a nasogastric tube
Answer: b) Encourage deep breathing and ambulation
Rationale: After surgery, encouraging ambulation and deep breathing
helps promote bowel motility and gas passage. It is important to allow
the patient to mobilize as soon as possible to reduce the risk of
complications such as ileus.
,3. A nurse is caring for a patient with congestive heart failure (CHF).
The nurse notes the patient has a decreased oxygen saturation level
and crackles in the lungs. What is the most likely cause of these
findings?
a) Pulmonary embolism
b) Pneumonia
c) Fluid overload
d) Myocardial infarction
Answer: c) Fluid overload
Rationale: In CHF, the heart is unable to pump effectively, leading to
fluid buildup in the lungs (pulmonary edema), which causes crackles
and decreased oxygen saturation levels. This is a common complication
of heart failure.
4. A nurse is caring for a patient with type 1 diabetes mellitus. The
nurse notes the patient is confused, weak, and has a blood glucose
level of 45 mg/dL. What should the nurse do first?
a) Administer insulin
b) Give the patient a sugary drink
c) Provide a low-fat snack
d) Call the healthcare provider
Answer: b) Give the patient a sugary drink
Rationale: The patient's symptoms indicate hypoglycemia, which
requires immediate treatment with a fast-acting carbohydrate, such as a
sugary drink. Insulin should not be administered in this case because it
would worsen hypoglycemia.
, 5. A nurse is teaching a patient about discharge instructions after a
mastectomy. Which of the following statements indicates that the
patient understands the teaching?
a) “I will wear my compression garment for the next few weeks.”
b) “I should avoid lifting my arm above my head for the next 6 months.”
c) “I can return to work in 1 week if I feel well enough.”
d) “I will monitor the surgical site for redness and swelling.”
Answer: d) “I will monitor the surgical site for redness and swelling.”
Rationale: After mastectomy, the patient should monitor the surgical
site for signs of infection, including redness, swelling, and discharge.
The patient should avoid lifting heavy objects or straining the arm but
can gradually regain movement with physical therapy as recommended
by the healthcare provider.
6. A nurse is caring for a patient receiving morphine for pain
management. The nurse notes that the patient is becoming drowsy,
has slow respirations, and is difficult to arouse. What is the priority
intervention?
a) Administer naloxone
b) Increase the dose of morphine
c) Elevate the head of the bed
d) Offer oral fluids
Answer: a) Administer naloxone
Rationale: The patient is showing signs of opioid overdose (respiratory
depression, drowsiness, difficulty arousing). Naloxone (an opioid
antagonist) should be administered immediately to reverse the effects
of morphine.
and starts to develop chills and fever. What should the nurse do first?
a) Notify the healthcare provider
b) Stop the transfusion
c) Administer antipyretic medication
d) Check the patient’s vital signs
Answer: b) Stop the transfusion
Rationale: The first priority when a transfusion reaction occurs (e.g.,
chills and fever) is to stop the transfusion immediately to prevent
further complications. After stopping the transfusion, the nurse should
notify the healthcare provider and follow protocol for managing the
transfusion reaction.
2. A nurse is caring for a patient post-appendectomy. The patient is
having difficulty passing gas. What is the most appropriate action for
the nurse to take?
a) Increase oral fluid intake
b) Encourage deep breathing and ambulation
c) Administer a stool softener
d) Insert a nasogastric tube
Answer: b) Encourage deep breathing and ambulation
Rationale: After surgery, encouraging ambulation and deep breathing
helps promote bowel motility and gas passage. It is important to allow
the patient to mobilize as soon as possible to reduce the risk of
complications such as ileus.
,3. A nurse is caring for a patient with congestive heart failure (CHF).
The nurse notes the patient has a decreased oxygen saturation level
and crackles in the lungs. What is the most likely cause of these
findings?
a) Pulmonary embolism
b) Pneumonia
c) Fluid overload
d) Myocardial infarction
Answer: c) Fluid overload
Rationale: In CHF, the heart is unable to pump effectively, leading to
fluid buildup in the lungs (pulmonary edema), which causes crackles
and decreased oxygen saturation levels. This is a common complication
of heart failure.
4. A nurse is caring for a patient with type 1 diabetes mellitus. The
nurse notes the patient is confused, weak, and has a blood glucose
level of 45 mg/dL. What should the nurse do first?
a) Administer insulin
b) Give the patient a sugary drink
c) Provide a low-fat snack
d) Call the healthcare provider
Answer: b) Give the patient a sugary drink
Rationale: The patient's symptoms indicate hypoglycemia, which
requires immediate treatment with a fast-acting carbohydrate, such as a
sugary drink. Insulin should not be administered in this case because it
would worsen hypoglycemia.
, 5. A nurse is teaching a patient about discharge instructions after a
mastectomy. Which of the following statements indicates that the
patient understands the teaching?
a) “I will wear my compression garment for the next few weeks.”
b) “I should avoid lifting my arm above my head for the next 6 months.”
c) “I can return to work in 1 week if I feel well enough.”
d) “I will monitor the surgical site for redness and swelling.”
Answer: d) “I will monitor the surgical site for redness and swelling.”
Rationale: After mastectomy, the patient should monitor the surgical
site for signs of infection, including redness, swelling, and discharge.
The patient should avoid lifting heavy objects or straining the arm but
can gradually regain movement with physical therapy as recommended
by the healthcare provider.
6. A nurse is caring for a patient receiving morphine for pain
management. The nurse notes that the patient is becoming drowsy,
has slow respirations, and is difficult to arouse. What is the priority
intervention?
a) Administer naloxone
b) Increase the dose of morphine
c) Elevate the head of the bed
d) Offer oral fluids
Answer: a) Administer naloxone
Rationale: The patient is showing signs of opioid overdose (respiratory
depression, drowsiness, difficulty arousing). Naloxone (an opioid
antagonist) should be administered immediately to reverse the effects
of morphine.
