1. A nurse is caring for a client who has diabetes mellitus and is
scheduled for surgery. The nurse should identify that which of the
following preoperative instructions is important for this client?
A. Discontinue insulin the morning of surgery. B. Increase fluid intake to
prevent dehydration. C. Eat a light meal before surgery. D. Administer
insulin as prescribed the morning of surgery.
Answer: D. Administer insulin as prescribed the morning of surgery.
Rationale: Clients with diabetes should manage their insulin regimen
before surgery. It is important to administer insulin as prescribed to
control blood glucose levels. Withholding insulin can lead to
hyperglycemia and complications during surgery. Fluid intake and meal
instructions depend on the specific surgery and anesthesia type.
2. A nurse is preparing a client for a thoracentesis. Which of the
following actions should the nurse take first?
A. Obtain a signed consent form from the client. B. Position the client
sitting upright with arms supported. C. Administer a sedative as
prescribed. D. Check the client's vital signs.
Answer: B. Position the client sitting upright with arms supported.
Rationale: Positioning the client is the priority step in preparing for a
thoracentesis, as it helps to expose the area for the procedure and
allows for better access to the pleural space. Once the position is
established, other actions, such as obtaining consent and checking vital
signs, can follow.
3. A nurse is caring for a postoperative client who has a wound
infection. The nurse notes increased redness and warmth around the
,wound, along with drainage that is greenish and foul-smelling. What is
the most appropriate nursing action?
A. Apply a fresh dressing to the wound and document findings. B. Notify
the healthcare provider and obtain a wound culture. C. Administer pain
medication as prescribed. D. Instruct the client to limit movement to
prevent wound disruption.
Answer: B. Notify the healthcare provider and obtain a wound culture.
Rationale: Increased redness, warmth, and foul-smelling drainage
indicate signs of infection. The nurse should notify the healthcare
provider and obtain a wound culture to determine the causative
organism and guide treatment. A fresh dressing is important but is
secondary to obtaining a culture for diagnosis.
4. A nurse is assessing a client with a diagnosis of heart failure. Which
of the following findings should the nurse report to the healthcare
provider?
A. A weight gain of 1 kg (2.2 lb) over the past 24 hours. B. Mild
shortness of breath on exertion. C. Ankle edema that improves with
elevation. D. A decrease in urine output.
Answer: A. A weight gain of 1 kg (2.2 lb) over the past 24 hours.
Rationale: A weight gain of 1 kg (2.2 lb) over 24 hours is a significant
indicator of fluid retention, which is a major concern in clients with
heart failure. This requires prompt attention from the healthcare
provider to assess for worsening heart failure and to adjust treatment
as necessary.
, 5. A nurse is caring for a client who is receiving intravenous (IV) fluid
replacement for dehydration. The nurse notes that the client’s urine
output is decreased. Which of the following actions should the nurse
take first?
A. Notify the healthcare provider of the decreased urine output. B.
Check the IV site for signs of infiltration. C. Increase the rate of IV fluid
infusion. D. Administer a diuretic as prescribed.
Answer: B. Check the IV site for signs of infiltration.
Rationale: Decreased urine output may be caused by issues with the IV
infusion, such as infiltration. The nurse should first assess the IV site for
signs of infiltration (e.g., swelling, redness, or coolness at the site)
before considering other actions.
6. A nurse is caring for a client who is receiving chemotherapy for
breast cancer. The nurse should instruct the client to report which of
the following findings immediately?
A. Sore throat B. Loss of appetite C. Fatigue D. Nausea
Answer: A. Sore throat.
Rationale: A sore throat could indicate a possible infection, which can
be serious for a client receiving chemotherapy due to their weakened
immune system. Infections should be addressed immediately to prevent
complications. The other symptoms are common side effects of
chemotherapy.
7. A nurse is caring for a client who has a chest tube in place following
surgery. The nurse notes that the water seal chamber is bubbling
scheduled for surgery. The nurse should identify that which of the
following preoperative instructions is important for this client?
A. Discontinue insulin the morning of surgery. B. Increase fluid intake to
prevent dehydration. C. Eat a light meal before surgery. D. Administer
insulin as prescribed the morning of surgery.
Answer: D. Administer insulin as prescribed the morning of surgery.
Rationale: Clients with diabetes should manage their insulin regimen
before surgery. It is important to administer insulin as prescribed to
control blood glucose levels. Withholding insulin can lead to
hyperglycemia and complications during surgery. Fluid intake and meal
instructions depend on the specific surgery and anesthesia type.
2. A nurse is preparing a client for a thoracentesis. Which of the
following actions should the nurse take first?
A. Obtain a signed consent form from the client. B. Position the client
sitting upright with arms supported. C. Administer a sedative as
prescribed. D. Check the client's vital signs.
Answer: B. Position the client sitting upright with arms supported.
Rationale: Positioning the client is the priority step in preparing for a
thoracentesis, as it helps to expose the area for the procedure and
allows for better access to the pleural space. Once the position is
established, other actions, such as obtaining consent and checking vital
signs, can follow.
3. A nurse is caring for a postoperative client who has a wound
infection. The nurse notes increased redness and warmth around the
,wound, along with drainage that is greenish and foul-smelling. What is
the most appropriate nursing action?
A. Apply a fresh dressing to the wound and document findings. B. Notify
the healthcare provider and obtain a wound culture. C. Administer pain
medication as prescribed. D. Instruct the client to limit movement to
prevent wound disruption.
Answer: B. Notify the healthcare provider and obtain a wound culture.
Rationale: Increased redness, warmth, and foul-smelling drainage
indicate signs of infection. The nurse should notify the healthcare
provider and obtain a wound culture to determine the causative
organism and guide treatment. A fresh dressing is important but is
secondary to obtaining a culture for diagnosis.
4. A nurse is assessing a client with a diagnosis of heart failure. Which
of the following findings should the nurse report to the healthcare
provider?
A. A weight gain of 1 kg (2.2 lb) over the past 24 hours. B. Mild
shortness of breath on exertion. C. Ankle edema that improves with
elevation. D. A decrease in urine output.
Answer: A. A weight gain of 1 kg (2.2 lb) over the past 24 hours.
Rationale: A weight gain of 1 kg (2.2 lb) over 24 hours is a significant
indicator of fluid retention, which is a major concern in clients with
heart failure. This requires prompt attention from the healthcare
provider to assess for worsening heart failure and to adjust treatment
as necessary.
, 5. A nurse is caring for a client who is receiving intravenous (IV) fluid
replacement for dehydration. The nurse notes that the client’s urine
output is decreased. Which of the following actions should the nurse
take first?
A. Notify the healthcare provider of the decreased urine output. B.
Check the IV site for signs of infiltration. C. Increase the rate of IV fluid
infusion. D. Administer a diuretic as prescribed.
Answer: B. Check the IV site for signs of infiltration.
Rationale: Decreased urine output may be caused by issues with the IV
infusion, such as infiltration. The nurse should first assess the IV site for
signs of infiltration (e.g., swelling, redness, or coolness at the site)
before considering other actions.
6. A nurse is caring for a client who is receiving chemotherapy for
breast cancer. The nurse should instruct the client to report which of
the following findings immediately?
A. Sore throat B. Loss of appetite C. Fatigue D. Nausea
Answer: A. Sore throat.
Rationale: A sore throat could indicate a possible infection, which can
be serious for a client receiving chemotherapy due to their weakened
immune system. Infections should be addressed immediately to prevent
complications. The other symptoms are common side effects of
chemotherapy.
7. A nurse is caring for a client who has a chest tube in place following
surgery. The nurse notes that the water seal chamber is bubbling
