Question 1:
A nurse is caring for a client who is recovering from surgery. The nurse
assesses the client’s surgical site and notices redness, swelling, and
warmth. Which action should the nurse take first?
a) Apply ice to the area.
b) Document the findings.
c) Notify the healthcare provider.
d) Assess for signs of infection.
Answer: d) Assess for signs of infection.
Rationale:
Before taking further action, the nurse should first assess for additional
signs of infection such as drainage, fever, or pain. This will guide the
appropriate interventions.
Question 2:
A nurse is caring for a client with a history of chronic obstructive
pulmonary disease (COPD) who is experiencing shortness of breath.
Which action should the nurse take first?
a) Administer supplemental oxygen.
b) Assess the client’s lung sounds.
c) Position the client in a semi-Fowler’s position.
d) Notify the healthcare provider.
Answer: b) Assess the client’s lung sounds.
Rationale:
Assessing lung sounds is important in determining the extent of the
client’s respiratory distress and can help prioritize interventions. Oxygen
may be administered, but assessment takes priority.
,Question 3:
A nurse is preparing to administer an intravenous (IV) medication. The
nurse should verify which of the following before administering the
medication?
a) The client’s allergies.
b) The client’s weight.
c) The client’s urine output.
d) The client’s last meal time.
Answer: a) The client’s allergies.
Rationale:
Verifying the client’s allergies is critical before administering any
medication to prevent adverse reactions.
Question 4:
A client with heart failure is prescribed a loop diuretic. The nurse should
monitor for which of the following adverse effects?
a) Hyperkalemia.
b) Hyperglycemia.
c) Hypokalemia.
d) Hyponatremia.
Answer: c) Hypokalemia.
Rationale:
Loop diuretics can lead to potassium loss, which may result in
hypokalemia. The nurse should monitor the client’s potassium levels
closely.
, Question 5:
A client with diabetes mellitus is admitted with a blood glucose level of
450 mg/dL. The nurse should anticipate the administration of which of
the following?
a) Oral hypoglycemic agents.
b) Insulin.
c) Glucagon.
d) A glucose bolus.
Answer: b) Insulin.
Rationale:
A blood glucose level of 450 mg/dL is indicative of hyperglycemia, and
the appropriate intervention is the administration of insulin to lower
the blood glucose level.
Question 6:
A nurse is caring for a client who is 2 days post-operative from an
abdominal surgery. The client is experiencing abdominal distension and
nausea. Which of the following is the priority action?
a) Assess the client’s vital signs.
b) Administer an antiemetic.
c) Monitor the client’s bowel sounds.
d) Encourage deep breathing exercises.
Answer: c) Monitor the client’s bowel sounds.
Rationale:
Abdominal distension and nausea after surgery may indicate bowel
A nurse is caring for a client who is recovering from surgery. The nurse
assesses the client’s surgical site and notices redness, swelling, and
warmth. Which action should the nurse take first?
a) Apply ice to the area.
b) Document the findings.
c) Notify the healthcare provider.
d) Assess for signs of infection.
Answer: d) Assess for signs of infection.
Rationale:
Before taking further action, the nurse should first assess for additional
signs of infection such as drainage, fever, or pain. This will guide the
appropriate interventions.
Question 2:
A nurse is caring for a client with a history of chronic obstructive
pulmonary disease (COPD) who is experiencing shortness of breath.
Which action should the nurse take first?
a) Administer supplemental oxygen.
b) Assess the client’s lung sounds.
c) Position the client in a semi-Fowler’s position.
d) Notify the healthcare provider.
Answer: b) Assess the client’s lung sounds.
Rationale:
Assessing lung sounds is important in determining the extent of the
client’s respiratory distress and can help prioritize interventions. Oxygen
may be administered, but assessment takes priority.
,Question 3:
A nurse is preparing to administer an intravenous (IV) medication. The
nurse should verify which of the following before administering the
medication?
a) The client’s allergies.
b) The client’s weight.
c) The client’s urine output.
d) The client’s last meal time.
Answer: a) The client’s allergies.
Rationale:
Verifying the client’s allergies is critical before administering any
medication to prevent adverse reactions.
Question 4:
A client with heart failure is prescribed a loop diuretic. The nurse should
monitor for which of the following adverse effects?
a) Hyperkalemia.
b) Hyperglycemia.
c) Hypokalemia.
d) Hyponatremia.
Answer: c) Hypokalemia.
Rationale:
Loop diuretics can lead to potassium loss, which may result in
hypokalemia. The nurse should monitor the client’s potassium levels
closely.
, Question 5:
A client with diabetes mellitus is admitted with a blood glucose level of
450 mg/dL. The nurse should anticipate the administration of which of
the following?
a) Oral hypoglycemic agents.
b) Insulin.
c) Glucagon.
d) A glucose bolus.
Answer: b) Insulin.
Rationale:
A blood glucose level of 450 mg/dL is indicative of hyperglycemia, and
the appropriate intervention is the administration of insulin to lower
the blood glucose level.
Question 6:
A nurse is caring for a client who is 2 days post-operative from an
abdominal surgery. The client is experiencing abdominal distension and
nausea. Which of the following is the priority action?
a) Assess the client’s vital signs.
b) Administer an antiemetic.
c) Monitor the client’s bowel sounds.
d) Encourage deep breathing exercises.
Answer: c) Monitor the client’s bowel sounds.
Rationale:
Abdominal distension and nausea after surgery may indicate bowel
