1. A nurse is caring for a client who is experiencing hyperkalemia.
Which of the following interventions should the nurse prioritize?
A) Administer sodium bicarbonate
B) Administer calcium gluconate
C) Administer insulin
D) Encourage oral potassium intake
Answer: B) Administer calcium gluconate
Rationale: Calcium gluconate helps to stabilize the cardiac membrane
and can help prevent life-threatening arrhythmias caused by
hyperkalemia. While other interventions like sodium bicarbonate or
insulin help lower potassium levels, calcium gluconate is the priority for
immediate stabilization.
2. A client is scheduled for a colonoscopy. The nurse is providing
preoperative teaching. Which of the following instructions should the
nurse include?
A) "You will be placed under general anesthesia for this procedure."
B) "You will need to drink a contrast solution the day before the
procedure."
C) "You should not eat or drink for 12 hours before the procedure."
D) "You will need to take a laxative to clear your bowels before the
procedure."
Answer: D) "You will need to take a laxative to clear your bowels
before the procedure."
Rationale: Colonoscopy requires a clear bowel for optimal visualization.
A bowel prep that includes laxatives and clear liquids is necessary to
clear the intestines. The procedure is usually performed with conscious
,sedation, not general anesthesia, and fasting instructions are typically
8–12 hours, not 12 hours.
3. A nurse is caring for a client with heart failure. The nurse
understands that which of the following is the primary goal of
treatment for this client?
A) To eliminate excess fluid from the body
B) To improve contractility of the heart muscle
C) To decrease the workload of the heart
D) To improve the client's overall quality of life
Answer: C) To decrease the workload of the heart
Rationale: The primary goal in heart failure treatment is to reduce the
workload of the heart. This is achieved through medications such as
ACE inhibitors, diuretics, and beta-blockers. While fluid removal and
contractility improvement are important, the most important long-term
goal is reducing the heart's workload.
4. A nurse is caring for a client who has just had a stroke and is
exhibiting signs of aphasia. The nurse should:
A) Speak louder to the client
B) Provide written communication for the client
C) Ask the client to speak in simple sentences
D) Encourage the client to communicate with gestures
Answer: B) Provide written communication for the client
Rationale: Aphasia is a communication disorder that affects speaking,
understanding, reading, or writing. Providing written communication
helps the client understand and express themselves better. Speaking
, louder or asking the client to speak in simple sentences may not be
effective in this case, and encouraging gestures is not a comprehensive
strategy.
5. A client with chronic obstructive pulmonary disease (COPD) is being
discharged from the hospital. The nurse should teach the client to:
A) Use oxygen therapy only during exercise
B) Avoid coughing as it increases the risk of infections
C) Maintain a low-calorie diet to prevent weight gain
D) Perform pursed-lip breathing to promote exhalation
Answer: D) Perform pursed-lip breathing to promote exhalation
Rationale: Pursed-lip breathing helps to control the rate and depth of
breathing and promotes exhalation, which is beneficial for clients with
COPD. The other options are either ineffective or inappropriate for
managing COPD.
6. A nurse is assessing a client with diabetes mellitus and notes that
the client has a fruity odor to their breath. The nurse should suspect
that the client:
A) Is experiencing hypoglycemia
B) Has an infection
C) Is developing diabetic ketoacidosis (DKA)
D) Is dehydrated
Answer: C) Is developing diabetic ketoacidosis (DKA)
Rationale: Fruity-smelling breath is a classic sign of diabetic
ketoacidosis (DKA), which occurs due to high blood sugar and the
Which of the following interventions should the nurse prioritize?
A) Administer sodium bicarbonate
B) Administer calcium gluconate
C) Administer insulin
D) Encourage oral potassium intake
Answer: B) Administer calcium gluconate
Rationale: Calcium gluconate helps to stabilize the cardiac membrane
and can help prevent life-threatening arrhythmias caused by
hyperkalemia. While other interventions like sodium bicarbonate or
insulin help lower potassium levels, calcium gluconate is the priority for
immediate stabilization.
2. A client is scheduled for a colonoscopy. The nurse is providing
preoperative teaching. Which of the following instructions should the
nurse include?
A) "You will be placed under general anesthesia for this procedure."
B) "You will need to drink a contrast solution the day before the
procedure."
C) "You should not eat or drink for 12 hours before the procedure."
D) "You will need to take a laxative to clear your bowels before the
procedure."
Answer: D) "You will need to take a laxative to clear your bowels
before the procedure."
Rationale: Colonoscopy requires a clear bowel for optimal visualization.
A bowel prep that includes laxatives and clear liquids is necessary to
clear the intestines. The procedure is usually performed with conscious
,sedation, not general anesthesia, and fasting instructions are typically
8–12 hours, not 12 hours.
3. A nurse is caring for a client with heart failure. The nurse
understands that which of the following is the primary goal of
treatment for this client?
A) To eliminate excess fluid from the body
B) To improve contractility of the heart muscle
C) To decrease the workload of the heart
D) To improve the client's overall quality of life
Answer: C) To decrease the workload of the heart
Rationale: The primary goal in heart failure treatment is to reduce the
workload of the heart. This is achieved through medications such as
ACE inhibitors, diuretics, and beta-blockers. While fluid removal and
contractility improvement are important, the most important long-term
goal is reducing the heart's workload.
4. A nurse is caring for a client who has just had a stroke and is
exhibiting signs of aphasia. The nurse should:
A) Speak louder to the client
B) Provide written communication for the client
C) Ask the client to speak in simple sentences
D) Encourage the client to communicate with gestures
Answer: B) Provide written communication for the client
Rationale: Aphasia is a communication disorder that affects speaking,
understanding, reading, or writing. Providing written communication
helps the client understand and express themselves better. Speaking
, louder or asking the client to speak in simple sentences may not be
effective in this case, and encouraging gestures is not a comprehensive
strategy.
5. A client with chronic obstructive pulmonary disease (COPD) is being
discharged from the hospital. The nurse should teach the client to:
A) Use oxygen therapy only during exercise
B) Avoid coughing as it increases the risk of infections
C) Maintain a low-calorie diet to prevent weight gain
D) Perform pursed-lip breathing to promote exhalation
Answer: D) Perform pursed-lip breathing to promote exhalation
Rationale: Pursed-lip breathing helps to control the rate and depth of
breathing and promotes exhalation, which is beneficial for clients with
COPD. The other options are either ineffective or inappropriate for
managing COPD.
6. A nurse is assessing a client with diabetes mellitus and notes that
the client has a fruity odor to their breath. The nurse should suspect
that the client:
A) Is experiencing hypoglycemia
B) Has an infection
C) Is developing diabetic ketoacidosis (DKA)
D) Is dehydrated
Answer: C) Is developing diabetic ketoacidosis (DKA)
Rationale: Fruity-smelling breath is a classic sign of diabetic
ketoacidosis (DKA), which occurs due to high blood sugar and the
