Question 1:
A nurse is caring for a client who has been diagnosed with heart
failure. Which of the following findings would be the most important
for the nurse to report to the healthcare provider immediately?
A) The client reports shortness of breath when walking.
B) The client has a productive cough with white sputum.
C) The client has bilateral edema in the lower extremities.
D) The client has jugular vein distention (JVD) and increased weight.
Answer: D) The client has jugular vein distention (JVD) and increased
weight.
Rationale: JVD and an increase in weight are signs of fluid retention,
which can indicate worsening heart failure. This requires immediate
attention by the healthcare provider to adjust treatment or
medications.
Question 2:
A nurse is caring for a client following a laparoscopic cholecystectomy.
The nurse should anticipate which of the following as a common
postoperative complication?
A) Deep vein thrombosis (DVT)
B) Wound infection
C) Bile leak
D) Hemorrhage
Answer: C) Bile leak
Rationale: After a laparoscopic cholecystectomy, a common
postoperative complication is a bile leak due to the surgical
,manipulation of the bile ducts. The nurse should monitor for signs of
bile leakage, such as abdominal pain or jaundice.
Question 3:
A nurse is assessing a client with a history of asthma. Which of the
following findings would be considered a priority in the nursing
assessment?
A) Wheezing upon exhalation
B) Decreased breath sounds and dull percussion over the lower lungs
C) Increased respiratory rate of 24 breaths per minute
D) Clear sputum production
Answer: B) Decreased breath sounds and dull percussion over the lower
lungs
Rationale: Decreased breath sounds and dull percussion may indicate
respiratory compromise or atelectasis, which could be more urgent
than wheezing or mild increased respiratory rate. The nurse should
prioritize further assessment and potentially assist with treatment.
Question 4:
A nurse is providing teaching to a client who is to undergo a
colonoscopy. Which of the following instructions is most important for
the nurse to include in the pre-procedure teaching?
A) "You will need to remain NPO for 24 hours before the procedure."
B) "You should take a laxative the night before the procedure."
C) "You may drink clear liquids until the morning of the procedure."
D) "You can take your usual medications the morning of the procedure."
, Answer: B) "You should take a laxative the night before the procedure."
Rationale: A colonoscopy requires the bowel to be clean. The client is
typically instructed to take a laxative the night before to ensure proper
bowel preparation. Clear liquids may be consumed until a certain point
before the procedure, but not until the morning.
Question 5:
A nurse is caring for a client with a diagnosis of pneumonia. Which of
the following interventions should the nurse implement to promote
airway clearance?
A) Administer oxygen via nasal cannula at 4 L/min
B) Encourage the client to increase fluid intake
C) Place the client in a supine position
D) Administer a sedative to promote rest
Answer: B) Encourage the client to increase fluid intake
Rationale: Increasing fluid intake helps thin secretions, making it easier
to clear mucus from the airways. Oxygen therapy may be necessary, but
promoting hydration is a priority for airway clearance.
Question 6:
A nurse is caring for a client with a recent diagnosis of diabetes
mellitus type 2. Which of the following teaching points is most
important for the nurse to emphasize for preventing complications?
A) "You should check your blood sugar levels every day before meals."
B) "You should rotate the sites of your insulin injections to prevent
tissue damage."
A nurse is caring for a client who has been diagnosed with heart
failure. Which of the following findings would be the most important
for the nurse to report to the healthcare provider immediately?
A) The client reports shortness of breath when walking.
B) The client has a productive cough with white sputum.
C) The client has bilateral edema in the lower extremities.
D) The client has jugular vein distention (JVD) and increased weight.
Answer: D) The client has jugular vein distention (JVD) and increased
weight.
Rationale: JVD and an increase in weight are signs of fluid retention,
which can indicate worsening heart failure. This requires immediate
attention by the healthcare provider to adjust treatment or
medications.
Question 2:
A nurse is caring for a client following a laparoscopic cholecystectomy.
The nurse should anticipate which of the following as a common
postoperative complication?
A) Deep vein thrombosis (DVT)
B) Wound infection
C) Bile leak
D) Hemorrhage
Answer: C) Bile leak
Rationale: After a laparoscopic cholecystectomy, a common
postoperative complication is a bile leak due to the surgical
,manipulation of the bile ducts. The nurse should monitor for signs of
bile leakage, such as abdominal pain or jaundice.
Question 3:
A nurse is assessing a client with a history of asthma. Which of the
following findings would be considered a priority in the nursing
assessment?
A) Wheezing upon exhalation
B) Decreased breath sounds and dull percussion over the lower lungs
C) Increased respiratory rate of 24 breaths per minute
D) Clear sputum production
Answer: B) Decreased breath sounds and dull percussion over the lower
lungs
Rationale: Decreased breath sounds and dull percussion may indicate
respiratory compromise or atelectasis, which could be more urgent
than wheezing or mild increased respiratory rate. The nurse should
prioritize further assessment and potentially assist with treatment.
Question 4:
A nurse is providing teaching to a client who is to undergo a
colonoscopy. Which of the following instructions is most important for
the nurse to include in the pre-procedure teaching?
A) "You will need to remain NPO for 24 hours before the procedure."
B) "You should take a laxative the night before the procedure."
C) "You may drink clear liquids until the morning of the procedure."
D) "You can take your usual medications the morning of the procedure."
, Answer: B) "You should take a laxative the night before the procedure."
Rationale: A colonoscopy requires the bowel to be clean. The client is
typically instructed to take a laxative the night before to ensure proper
bowel preparation. Clear liquids may be consumed until a certain point
before the procedure, but not until the morning.
Question 5:
A nurse is caring for a client with a diagnosis of pneumonia. Which of
the following interventions should the nurse implement to promote
airway clearance?
A) Administer oxygen via nasal cannula at 4 L/min
B) Encourage the client to increase fluid intake
C) Place the client in a supine position
D) Administer a sedative to promote rest
Answer: B) Encourage the client to increase fluid intake
Rationale: Increasing fluid intake helps thin secretions, making it easier
to clear mucus from the airways. Oxygen therapy may be necessary, but
promoting hydration is a priority for airway clearance.
Question 6:
A nurse is caring for a client with a recent diagnosis of diabetes
mellitus type 2. Which of the following teaching points is most
important for the nurse to emphasize for preventing complications?
A) "You should check your blood sugar levels every day before meals."
B) "You should rotate the sites of your insulin injections to prevent
tissue damage."
