1. A nurse is caring for a patient who is 2 days postoperative following
a laparoscopic cholecystectomy. Which of the following is the priority
assessment to monitor for complications?
A) Pain level
B) Abdominal distention
C) Blood pressure
D) Heart rate
Answer: B) Abdominal distention
Rationale: Abdominal distention could indicate complications such as a
bile leak or gastrointestinal obstruction. Monitoring for these signs is a
priority in the early postoperative period after gallbladder surgery.
2. A nurse is preparing to administer an oral medication to a client
with dysphagia. Which action should the nurse take to ensure the
medication is safely administered?
A) Crush the tablet and mix with applesauce
B) Ask the client to swallow the medication with a sip of water
C) Open the capsule and pour the contents into water
D) Place the medication on the back of the client's throat
Answer: A) Crush the tablet and mix with applesauce
Rationale: For a patient with dysphagia, crushing the medication and
mixing it with a soft food, like applesauce, can help them swallow it
more easily. However, it is important to check if the medication can
safely be crushed (some medications cannot be crushed).
3. A nurse is caring for a client with acute pancreatitis. Which of the
following should the nurse monitor for as a priority?
,A) Hypertension
B) Hypoglycemia
C) Electrolyte imbalances
D) Decreased urine output
Answer: C) Electrolyte imbalances
Rationale: Acute pancreatitis can cause electrolyte imbalances,
particularly hypocalcemia and hypokalemia, due to the release of
pancreatic enzymes and subsequent inflammation. Monitoring
electrolyte levels is critical.
4. A nurse is providing discharge teaching for a client with a new
prescription for warfarin. Which of the following statements by the
client indicates a need for further teaching?
A) "I will take the medication at the same time every day."
B) "I should avoid taking aspirin or any over-the-counter medications
without talking to my doctor."
C) "I will increase my intake of green leafy vegetables."
D) "I should wear a medical alert bracelet indicating I take warfarin."
Answer: C) "I will increase my intake of green leafy vegetables."
Rationale: Warfarin is an anticoagulant that works by inhibiting vitamin
K, which is found in green leafy vegetables. Increasing intake of these
foods can interfere with the drug’s effectiveness. The client should
maintain a consistent intake of vitamin K.
5. A nurse is caring for a client with a pressure ulcer. Which of the
following is the most important action to prevent further skin
breakdown?
, A) Reposition the client every 2 hours
B) Massage the bony prominences frequently
C) Increase the client's caloric intake
D) Apply a wet-to-dry dressing daily
Answer: A) Reposition the client every 2 hours
Rationale: Repositioning the patient every 2 hours helps relieve
pressure on bony prominences and prevents further skin breakdown.
Proper nutrition and moisture control are also important, but
repositioning is a direct intervention.
6. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). Which of the following findings is the nurse's priority
concern?
A) Barrel chest
B) O2 saturation of 88%
C) Use of accessory muscles during respiration
D) Expiratory wheezing
Answer: B) O2 saturation of 88%
Rationale: A low oxygen saturation of 88% is concerning for hypoxemia,
which is a priority to address in a patient with COPD. The nurse should
intervene to improve oxygenation, possibly by administering
supplemental oxygen.
7. A nurse is caring for a patient who is receiving a blood transfusion.
The patient suddenly develops chills and back pain. What is the
priority action?
a laparoscopic cholecystectomy. Which of the following is the priority
assessment to monitor for complications?
A) Pain level
B) Abdominal distention
C) Blood pressure
D) Heart rate
Answer: B) Abdominal distention
Rationale: Abdominal distention could indicate complications such as a
bile leak or gastrointestinal obstruction. Monitoring for these signs is a
priority in the early postoperative period after gallbladder surgery.
2. A nurse is preparing to administer an oral medication to a client
with dysphagia. Which action should the nurse take to ensure the
medication is safely administered?
A) Crush the tablet and mix with applesauce
B) Ask the client to swallow the medication with a sip of water
C) Open the capsule and pour the contents into water
D) Place the medication on the back of the client's throat
Answer: A) Crush the tablet and mix with applesauce
Rationale: For a patient with dysphagia, crushing the medication and
mixing it with a soft food, like applesauce, can help them swallow it
more easily. However, it is important to check if the medication can
safely be crushed (some medications cannot be crushed).
3. A nurse is caring for a client with acute pancreatitis. Which of the
following should the nurse monitor for as a priority?
,A) Hypertension
B) Hypoglycemia
C) Electrolyte imbalances
D) Decreased urine output
Answer: C) Electrolyte imbalances
Rationale: Acute pancreatitis can cause electrolyte imbalances,
particularly hypocalcemia and hypokalemia, due to the release of
pancreatic enzymes and subsequent inflammation. Monitoring
electrolyte levels is critical.
4. A nurse is providing discharge teaching for a client with a new
prescription for warfarin. Which of the following statements by the
client indicates a need for further teaching?
A) "I will take the medication at the same time every day."
B) "I should avoid taking aspirin or any over-the-counter medications
without talking to my doctor."
C) "I will increase my intake of green leafy vegetables."
D) "I should wear a medical alert bracelet indicating I take warfarin."
Answer: C) "I will increase my intake of green leafy vegetables."
Rationale: Warfarin is an anticoagulant that works by inhibiting vitamin
K, which is found in green leafy vegetables. Increasing intake of these
foods can interfere with the drug’s effectiveness. The client should
maintain a consistent intake of vitamin K.
5. A nurse is caring for a client with a pressure ulcer. Which of the
following is the most important action to prevent further skin
breakdown?
, A) Reposition the client every 2 hours
B) Massage the bony prominences frequently
C) Increase the client's caloric intake
D) Apply a wet-to-dry dressing daily
Answer: A) Reposition the client every 2 hours
Rationale: Repositioning the patient every 2 hours helps relieve
pressure on bony prominences and prevents further skin breakdown.
Proper nutrition and moisture control are also important, but
repositioning is a direct intervention.
6. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD). Which of the following findings is the nurse's priority
concern?
A) Barrel chest
B) O2 saturation of 88%
C) Use of accessory muscles during respiration
D) Expiratory wheezing
Answer: B) O2 saturation of 88%
Rationale: A low oxygen saturation of 88% is concerning for hypoxemia,
which is a priority to address in a patient with COPD. The nurse should
intervene to improve oxygenation, possibly by administering
supplemental oxygen.
7. A nurse is caring for a patient who is receiving a blood transfusion.
The patient suddenly develops chills and back pain. What is the
priority action?
