1. A nurse is caring for a client who is postoperative and receiving
opioids for pain control. The nurse notes that the client’s respiratory
rate is 8 breaths per minute and their oxygen saturation is 88%. Which
action should the nurse take first?
A) Administer a naloxone (Narcan) injection
B) Increase the oxygen flow rate
C) Assess the client’s pain level
D) Notify the healthcare provider
Answer: A) Administer a naloxone (Narcan) injection
Rationale: Naloxone is a medication that reverses the effects of opioid
overdose, including respiratory depression. The first action the nurse
should take in this situation is to administer naloxone to restore
respiratory function. After administering naloxone, the nurse can
provide oxygen, assess pain, and notify the healthcare provider.
2. A nurse is preparing to administer a diuretic to a client with
congestive heart failure. Which laboratory result should the nurse
assess before administering the medication?
A) Potassium level
B) Sodium level
C) Calcium level
D) Glucose level
Answer: A) Potassium level
Rationale: Diuretics, especially loop and thiazide diuretics, can cause
potassium depletion. Hypokalemia can lead to serious cardiac
arrhythmias, so the nurse should assess the potassium level before
administering the diuretic.
,3. A client with chronic obstructive pulmonary disease (COPD) is
admitted with increasing shortness of breath. The nurse notes that
the client is using accessory muscles to breathe. What is the nurse's
priority intervention?
A) Administer a bronchodilator
B) Perform chest physiotherapy
C) Increase the client's oxygen flow rate
D) Assist the client into a semi-Fowler’s position
Answer: A) Administer a bronchodilator
Rationale: The priority in this scenario is to administer a bronchodilator
to open the airways and improve breathing. While other interventions
(oxygen, positioning) may be helpful, bronchodilators directly address
the underlying cause of the shortness of breath.
4. A nurse is assessing a client who is receiving chemotherapy for
cancer. The client reports feeling fatigued and weak. Which laboratory
test result should the nurse monitor to determine if the fatigue is
related to the chemotherapy treatment?
A) White blood cell count
B) Platelet count
C) Hemoglobin level
D) Serum creatinine level
Answer: C) Hemoglobin level
Rationale: Chemotherapy can cause bone marrow suppression, leading
to decreased red blood cell production and resulting in anemia. Anemia
, is the most likely cause of fatigue in this client, so the nurse should
monitor the hemoglobin level.
5. A nurse is caring for a client with type 1 diabetes mellitus. The client
reports feeling shaky, sweaty, and dizzy. The nurse checks the client's
blood glucose level and finds it to be 50 mg/dL. Which is the priority
action?
A) Administer a dose of insulin
B) Provide the client with a glucose-containing drink
C) Notify the healthcare provider
D) Document the symptoms and assessment findings
Answer: B) Provide the client with a glucose-containing drink
Rationale: The client’s symptoms and blood glucose level of 50 mg/dL
indicate hypoglycemia. The priority action is to raise the client's blood
glucose level by giving a glucose-containing drink, such as juice or a
glucose tablet. Insulin should not be given in this situation.
6. A nurse is caring for a client with cirrhosis of the liver. The client is
experiencing confusion and altered mental status. Which condition is
most likely contributing to this change in mental status?
A) Hyperglycemia
B) Hypoxia
C) Hepatic encephalopathy
D) Hyperkalemia
Answer: C) Hepatic encephalopathy
Rationale: Hepatic encephalopathy is a common complication of
cirrhosis, caused by the liver’s inability to detoxify harmful substances
opioids for pain control. The nurse notes that the client’s respiratory
rate is 8 breaths per minute and their oxygen saturation is 88%. Which
action should the nurse take first?
A) Administer a naloxone (Narcan) injection
B) Increase the oxygen flow rate
C) Assess the client’s pain level
D) Notify the healthcare provider
Answer: A) Administer a naloxone (Narcan) injection
Rationale: Naloxone is a medication that reverses the effects of opioid
overdose, including respiratory depression. The first action the nurse
should take in this situation is to administer naloxone to restore
respiratory function. After administering naloxone, the nurse can
provide oxygen, assess pain, and notify the healthcare provider.
2. A nurse is preparing to administer a diuretic to a client with
congestive heart failure. Which laboratory result should the nurse
assess before administering the medication?
A) Potassium level
B) Sodium level
C) Calcium level
D) Glucose level
Answer: A) Potassium level
Rationale: Diuretics, especially loop and thiazide diuretics, can cause
potassium depletion. Hypokalemia can lead to serious cardiac
arrhythmias, so the nurse should assess the potassium level before
administering the diuretic.
,3. A client with chronic obstructive pulmonary disease (COPD) is
admitted with increasing shortness of breath. The nurse notes that
the client is using accessory muscles to breathe. What is the nurse's
priority intervention?
A) Administer a bronchodilator
B) Perform chest physiotherapy
C) Increase the client's oxygen flow rate
D) Assist the client into a semi-Fowler’s position
Answer: A) Administer a bronchodilator
Rationale: The priority in this scenario is to administer a bronchodilator
to open the airways and improve breathing. While other interventions
(oxygen, positioning) may be helpful, bronchodilators directly address
the underlying cause of the shortness of breath.
4. A nurse is assessing a client who is receiving chemotherapy for
cancer. The client reports feeling fatigued and weak. Which laboratory
test result should the nurse monitor to determine if the fatigue is
related to the chemotherapy treatment?
A) White blood cell count
B) Platelet count
C) Hemoglobin level
D) Serum creatinine level
Answer: C) Hemoglobin level
Rationale: Chemotherapy can cause bone marrow suppression, leading
to decreased red blood cell production and resulting in anemia. Anemia
, is the most likely cause of fatigue in this client, so the nurse should
monitor the hemoglobin level.
5. A nurse is caring for a client with type 1 diabetes mellitus. The client
reports feeling shaky, sweaty, and dizzy. The nurse checks the client's
blood glucose level and finds it to be 50 mg/dL. Which is the priority
action?
A) Administer a dose of insulin
B) Provide the client with a glucose-containing drink
C) Notify the healthcare provider
D) Document the symptoms and assessment findings
Answer: B) Provide the client with a glucose-containing drink
Rationale: The client’s symptoms and blood glucose level of 50 mg/dL
indicate hypoglycemia. The priority action is to raise the client's blood
glucose level by giving a glucose-containing drink, such as juice or a
glucose tablet. Insulin should not be given in this situation.
6. A nurse is caring for a client with cirrhosis of the liver. The client is
experiencing confusion and altered mental status. Which condition is
most likely contributing to this change in mental status?
A) Hyperglycemia
B) Hypoxia
C) Hepatic encephalopathy
D) Hyperkalemia
Answer: C) Hepatic encephalopathy
Rationale: Hepatic encephalopathy is a common complication of
cirrhosis, caused by the liver’s inability to detoxify harmful substances
