1. A nurse is caring for a postoperative client who is at risk for deep
vein thrombosis (DVT). Which of the following interventions should
the nurse prioritize?
A. Apply an abdominal binder
B. Encourage early ambulation
C. Administer a laxative
D. Provide a high-fiber diet
Answer: B. Encourage early ambulation
Rationale: Early ambulation is essential in preventing DVT by promoting
blood circulation and reducing the risk of clot formation. Abdominal
binders and laxatives are not indicated for DVT prevention. A high-fiber
diet is important for bowel health but does not directly impact the risk
of DVT.
2. A nurse is assessing a client with chronic obstructive pulmonary
disease (COPD). Which of the following findings would indicate that
the client is experiencing respiratory distress?
A. Oxygen saturation of 95%
B. Use of accessory muscles for breathing
C. Decreased respiratory rate
D. Clear lung sounds upon auscultation
Answer: B. Use of accessory muscles for breathing
Rationale: The use of accessory muscles for breathing is a clear sign of
respiratory distress, indicating that the client is struggling to breathe. An
oxygen saturation of 95% is within normal limits, and clear lung sounds
,typically indicate that the client is not in distress. A decreased
respiratory rate could indicate hypoventilation.
3. A nurse is caring for a client who is receiving a blood transfusion.
Which of the following signs indicates a potential transfusion
reaction?
A. Blood pressure 118/76 mm Hg
B. Client complains of back pain
C. Oxygen saturation of 97%
D. Temperature of 98.6°F
Answer: B. Client complains of back pain
Rationale: Back pain is a classic sign of an acute hemolytic transfusion
reaction, which occurs when there is a mismatch between the donor's
and recipient's blood types. Other signs of a transfusion reaction
include fever, chills, and hypotension. Normal vital signs do not suggest
a transfusion reaction.
4. A nurse is caring for a client with heart failure who is receiving
digoxin. Which of the following findings should the nurse report to the
healthcare provider?
A. Serum potassium level of 3.5 mEq/L
B. Apical pulse rate of 58 beats per minute
C. Blood pressure of 120/80 mm Hg
D. Oxygen saturation of 96%
Answer: B. Apical pulse rate of 58 beats per minute
Rationale: Digoxin can cause bradycardia, so an apical pulse rate of 58
beats per minute is concerning and should be reported. A potassium
, level of 3.5 mEq/L is normal, and normal blood pressure and oxygen
saturation are expected in a well-managed heart failure client.
5. A nurse is caring for a client with an indwelling urinary catheter.
Which of the following actions is most important to reduce the risk of
a urinary tract infection (UTI)?
A. Perform catheter care with soap and water twice a day
B. Ensure the catheter is secured to the client's leg
C. Irrigate the catheter with sterile saline daily
D. Keep the drainage bag above the level of the bladder
Answer: B. Ensure the catheter is secured to the client's leg
Rationale: Securing the catheter to the leg prevents tension on the
catheter, reducing the risk of displacement and trauma, which can lead
to infection. Keeping the drainage bag below the level of the bladder
reduces the risk of backflow, and catheter care should be done with the
right technique and frequency, but the priority is securing the catheter.
6. A nurse is caring for a client with diabetes mellitus who is being
treated for diabetic ketoacidosis (DKA). Which of the following
findings indicates that the treatment is effective?
A. Blood glucose level of 250 mg/dL
B. Blood pH of 7.35
C. Decreased urine output
D. Increased breath rate
Answer: B. Blood pH of 7.35
Rationale: The blood pH is a key indicator of acid-base balance, and a
pH of 7.35 suggests that the acidosis has resolved, which is an indicator
vein thrombosis (DVT). Which of the following interventions should
the nurse prioritize?
A. Apply an abdominal binder
B. Encourage early ambulation
C. Administer a laxative
D. Provide a high-fiber diet
Answer: B. Encourage early ambulation
Rationale: Early ambulation is essential in preventing DVT by promoting
blood circulation and reducing the risk of clot formation. Abdominal
binders and laxatives are not indicated for DVT prevention. A high-fiber
diet is important for bowel health but does not directly impact the risk
of DVT.
2. A nurse is assessing a client with chronic obstructive pulmonary
disease (COPD). Which of the following findings would indicate that
the client is experiencing respiratory distress?
A. Oxygen saturation of 95%
B. Use of accessory muscles for breathing
C. Decreased respiratory rate
D. Clear lung sounds upon auscultation
Answer: B. Use of accessory muscles for breathing
Rationale: The use of accessory muscles for breathing is a clear sign of
respiratory distress, indicating that the client is struggling to breathe. An
oxygen saturation of 95% is within normal limits, and clear lung sounds
,typically indicate that the client is not in distress. A decreased
respiratory rate could indicate hypoventilation.
3. A nurse is caring for a client who is receiving a blood transfusion.
Which of the following signs indicates a potential transfusion
reaction?
A. Blood pressure 118/76 mm Hg
B. Client complains of back pain
C. Oxygen saturation of 97%
D. Temperature of 98.6°F
Answer: B. Client complains of back pain
Rationale: Back pain is a classic sign of an acute hemolytic transfusion
reaction, which occurs when there is a mismatch between the donor's
and recipient's blood types. Other signs of a transfusion reaction
include fever, chills, and hypotension. Normal vital signs do not suggest
a transfusion reaction.
4. A nurse is caring for a client with heart failure who is receiving
digoxin. Which of the following findings should the nurse report to the
healthcare provider?
A. Serum potassium level of 3.5 mEq/L
B. Apical pulse rate of 58 beats per minute
C. Blood pressure of 120/80 mm Hg
D. Oxygen saturation of 96%
Answer: B. Apical pulse rate of 58 beats per minute
Rationale: Digoxin can cause bradycardia, so an apical pulse rate of 58
beats per minute is concerning and should be reported. A potassium
, level of 3.5 mEq/L is normal, and normal blood pressure and oxygen
saturation are expected in a well-managed heart failure client.
5. A nurse is caring for a client with an indwelling urinary catheter.
Which of the following actions is most important to reduce the risk of
a urinary tract infection (UTI)?
A. Perform catheter care with soap and water twice a day
B. Ensure the catheter is secured to the client's leg
C. Irrigate the catheter with sterile saline daily
D. Keep the drainage bag above the level of the bladder
Answer: B. Ensure the catheter is secured to the client's leg
Rationale: Securing the catheter to the leg prevents tension on the
catheter, reducing the risk of displacement and trauma, which can lead
to infection. Keeping the drainage bag below the level of the bladder
reduces the risk of backflow, and catheter care should be done with the
right technique and frequency, but the priority is securing the catheter.
6. A nurse is caring for a client with diabetes mellitus who is being
treated for diabetic ketoacidosis (DKA). Which of the following
findings indicates that the treatment is effective?
A. Blood glucose level of 250 mg/dL
B. Blood pH of 7.35
C. Decreased urine output
D. Increased breath rate
Answer: B. Blood pH of 7.35
Rationale: The blood pH is a key indicator of acid-base balance, and a
pH of 7.35 suggests that the acidosis has resolved, which is an indicator
