1. Question:
A nurse is caring for a client who is postoperative following abdominal
surgery. The nurse notes that the client is experiencing distention and
absent bowel sounds. What should the nurse do next?
A) Administer a prescribed antiemetic
B) Encourage early ambulation
C) Increase the IV fluids rate
D) Notify the healthcare provider
Answer: B) Encourage early ambulation
Rationale: Early ambulation is encouraged after surgery to promote
peristalsis and prevent complications like ileus. Distention and absent
bowel sounds can be signs of postoperative ileus, which improves with
movement.
2. Question:
A nurse is assessing a client with acute pancreatitis. Which finding is
most likely to indicate that the client is experiencing complications?
A) Decreased blood pressure
B) Hypoglycemia
C) Elevated blood glucose
D) Decreased pulse rate
Answer: A) Decreased blood pressure
Rationale: Decreased blood pressure can be indicative of hypovolemic
shock, which may occur due to the fluid shifts associated with
pancreatitis. This is a potential life-threatening complication.
3. Question:
,A client with congestive heart failure (CHF) is receiving a diuretic. The
nurse should monitor the client for which potential complication related
to the medication?
A) Hyperkalemia
B) Hypokalemia
C) Hypertension
D) Hypoglycemia
Answer: B) Hypokalemia
Rationale: Diuretics, especially loop diuretics (e.g., furosemide), can
cause the body to lose potassium, leading to hypokalemia. This
electrolyte imbalance can cause serious cardiac arrhythmias.
4. Question:
A nurse is providing discharge teaching to a client with a new diagnosis
of hypertension. Which statement by the client indicates the need for
further education?
A) "I will monitor my blood pressure regularly."
B) "I can stop my medication once my blood pressure returns to
normal."
C) "I will reduce my sodium intake."
D) "I will follow a low-fat diet to manage my blood pressure."
Answer: B) "I can stop my medication once my blood pressure returns
to normal."
Rationale: Hypertension is a chronic condition that requires ongoing
management. Discontinuing medication once blood pressure
normalizes can lead to a rebound increase in blood pressure and other
complications.
, 5. Question:
A nurse is caring for a client with a history of chronic obstructive
pulmonary disease (COPD). Which finding indicates that the client's
condition may be worsening?
A) Increased wheezing
B) Respiratory rate of 12 breaths/min
C) Oxygen saturation of 95%
D) Decreased sputum production
Answer: A) Increased wheezing
Rationale: Increased wheezing is a sign of airway constriction and
worsening respiratory status in COPD. The nurse should assess for signs
of increased work of breathing and further deterioration.
6. Question:
A nurse is caring for a client receiving a blood transfusion. Which of the
following is the most important to assess during the first 15 minutes of
the transfusion?
A) Temperature
B) Respiratory rate
C) Blood pressure
D) Pulse rate
Answer: A) Temperature
Rationale: The first 15 minutes of a blood transfusion are critical for
detecting an acute transfusion reaction, which may present with fever
or chills. Early detection allows for prompt intervention.
A nurse is caring for a client who is postoperative following abdominal
surgery. The nurse notes that the client is experiencing distention and
absent bowel sounds. What should the nurse do next?
A) Administer a prescribed antiemetic
B) Encourage early ambulation
C) Increase the IV fluids rate
D) Notify the healthcare provider
Answer: B) Encourage early ambulation
Rationale: Early ambulation is encouraged after surgery to promote
peristalsis and prevent complications like ileus. Distention and absent
bowel sounds can be signs of postoperative ileus, which improves with
movement.
2. Question:
A nurse is assessing a client with acute pancreatitis. Which finding is
most likely to indicate that the client is experiencing complications?
A) Decreased blood pressure
B) Hypoglycemia
C) Elevated blood glucose
D) Decreased pulse rate
Answer: A) Decreased blood pressure
Rationale: Decreased blood pressure can be indicative of hypovolemic
shock, which may occur due to the fluid shifts associated with
pancreatitis. This is a potential life-threatening complication.
3. Question:
,A client with congestive heart failure (CHF) is receiving a diuretic. The
nurse should monitor the client for which potential complication related
to the medication?
A) Hyperkalemia
B) Hypokalemia
C) Hypertension
D) Hypoglycemia
Answer: B) Hypokalemia
Rationale: Diuretics, especially loop diuretics (e.g., furosemide), can
cause the body to lose potassium, leading to hypokalemia. This
electrolyte imbalance can cause serious cardiac arrhythmias.
4. Question:
A nurse is providing discharge teaching to a client with a new diagnosis
of hypertension. Which statement by the client indicates the need for
further education?
A) "I will monitor my blood pressure regularly."
B) "I can stop my medication once my blood pressure returns to
normal."
C) "I will reduce my sodium intake."
D) "I will follow a low-fat diet to manage my blood pressure."
Answer: B) "I can stop my medication once my blood pressure returns
to normal."
Rationale: Hypertension is a chronic condition that requires ongoing
management. Discontinuing medication once blood pressure
normalizes can lead to a rebound increase in blood pressure and other
complications.
, 5. Question:
A nurse is caring for a client with a history of chronic obstructive
pulmonary disease (COPD). Which finding indicates that the client's
condition may be worsening?
A) Increased wheezing
B) Respiratory rate of 12 breaths/min
C) Oxygen saturation of 95%
D) Decreased sputum production
Answer: A) Increased wheezing
Rationale: Increased wheezing is a sign of airway constriction and
worsening respiratory status in COPD. The nurse should assess for signs
of increased work of breathing and further deterioration.
6. Question:
A nurse is caring for a client receiving a blood transfusion. Which of the
following is the most important to assess during the first 15 minutes of
the transfusion?
A) Temperature
B) Respiratory rate
C) Blood pressure
D) Pulse rate
Answer: A) Temperature
Rationale: The first 15 minutes of a blood transfusion are critical for
detecting an acute transfusion reaction, which may present with fever
or chills. Early detection allows for prompt intervention.
