1. A nurse is caring for a client who is 24 hours postoperative following
a cholecystectomy. The nurse observes that the client has a
temperature of 101°F (38.3°C), and the incision is warm, red, and
slightly edematous. Which action should the nurse take first?
A. Administer acetaminophen for fever.
B. Obtain a culture from the incision site.
C. Irrigate the incision site.
D. Notify the healthcare provider.
Answer: B. Obtain a culture from the incision site.
Rationale: The first action should be to assess for signs of infection.
Obtaining a culture will help identify whether an infection is present
before administering antibiotics or other interventions.
2. A nurse is providing education to a client about hypertension.
Which of the following statements by the client indicates the need for
further teaching?
A. "I will reduce my sodium intake to less than 2,300 mg per day."
B. "I will reduce my alcohol intake to no more than two drinks per day."
C. "I can take my blood pressure medication only when I feel my blood
pressure is high."
D. "I will start an exercise program and aim for 150 minutes of
moderate-intensity exercise per week."
Answer: C. "I can take my blood pressure medication only when I feel
my blood pressure is high."
,Rationale: Blood pressure medications should be taken as prescribed,
not only when the client feels symptoms. Consistent medication
adherence is key to managing hypertension.
3. A nurse is assessing a client with chronic kidney disease. Which of
the following findings would be most concerning?
A. Serum potassium level of 5.2 mEq/L
B. Serum creatinine level of 1.8 mg/dL
C. Urine output of 200 mL in 12 hours
D. Blood pressure of 130/80 mm Hg
Answer: C. Urine output of 200 mL in 12 hours.
Rationale: A significant decrease in urine output, such as oliguria (less
than 400 mL/day), is concerning for acute renal failure or worsening
chronic kidney disease. This requires immediate evaluation.
4. A nurse is caring for a client with a deep vein thrombosis (DVT). The
nurse understands that which of the following is a priority
intervention?
A. Administering pain medication as prescribed
B. Encouraging early ambulation
C. Administering anticoagulants as prescribed
D. Applying heat to the affected limb
Answer: C. Administering anticoagulants as prescribed.
Rationale: Anticoagulation therapy is crucial in preventing the clot from
growing larger and to prevent complications like a pulmonary
embolism. Ambulation and heat are not priorities before anticoagulant
administration.
, 5. A nurse is providing care to a client diagnosed with pneumonia. The
nurse understands that the most common cause of community-
acquired pneumonia is:
A. Staphylococcus aureus
B. Mycobacterium tuberculosis
C. Streptococcus pneumoniae
D. Escherichia coli
Answer: C. Streptococcus pneumoniae.
Rationale: Streptococcus pneumoniae is the most common pathogen
associated with community-acquired pneumonia. Other pathogens may
be involved, but this is the most frequent cause.
6. A nurse is caring for a client with a history of asthma who is
admitted with shortness of breath and wheezing. The nurse should
assess for which of the following first?
A. Oxygen saturation level
B. Peak flow readings
C. Breath sounds
D. Arterial blood gases
Answer: C. Breath sounds.
Rationale: The most important assessment for a client with asthma who
is wheezing and short of breath is evaluating breath sounds. This can
help determine the severity of the bronchospasm and whether there is
a need for urgent intervention.
a cholecystectomy. The nurse observes that the client has a
temperature of 101°F (38.3°C), and the incision is warm, red, and
slightly edematous. Which action should the nurse take first?
A. Administer acetaminophen for fever.
B. Obtain a culture from the incision site.
C. Irrigate the incision site.
D. Notify the healthcare provider.
Answer: B. Obtain a culture from the incision site.
Rationale: The first action should be to assess for signs of infection.
Obtaining a culture will help identify whether an infection is present
before administering antibiotics or other interventions.
2. A nurse is providing education to a client about hypertension.
Which of the following statements by the client indicates the need for
further teaching?
A. "I will reduce my sodium intake to less than 2,300 mg per day."
B. "I will reduce my alcohol intake to no more than two drinks per day."
C. "I can take my blood pressure medication only when I feel my blood
pressure is high."
D. "I will start an exercise program and aim for 150 minutes of
moderate-intensity exercise per week."
Answer: C. "I can take my blood pressure medication only when I feel
my blood pressure is high."
,Rationale: Blood pressure medications should be taken as prescribed,
not only when the client feels symptoms. Consistent medication
adherence is key to managing hypertension.
3. A nurse is assessing a client with chronic kidney disease. Which of
the following findings would be most concerning?
A. Serum potassium level of 5.2 mEq/L
B. Serum creatinine level of 1.8 mg/dL
C. Urine output of 200 mL in 12 hours
D. Blood pressure of 130/80 mm Hg
Answer: C. Urine output of 200 mL in 12 hours.
Rationale: A significant decrease in urine output, such as oliguria (less
than 400 mL/day), is concerning for acute renal failure or worsening
chronic kidney disease. This requires immediate evaluation.
4. A nurse is caring for a client with a deep vein thrombosis (DVT). The
nurse understands that which of the following is a priority
intervention?
A. Administering pain medication as prescribed
B. Encouraging early ambulation
C. Administering anticoagulants as prescribed
D. Applying heat to the affected limb
Answer: C. Administering anticoagulants as prescribed.
Rationale: Anticoagulation therapy is crucial in preventing the clot from
growing larger and to prevent complications like a pulmonary
embolism. Ambulation and heat are not priorities before anticoagulant
administration.
, 5. A nurse is providing care to a client diagnosed with pneumonia. The
nurse understands that the most common cause of community-
acquired pneumonia is:
A. Staphylococcus aureus
B. Mycobacterium tuberculosis
C. Streptococcus pneumoniae
D. Escherichia coli
Answer: C. Streptococcus pneumoniae.
Rationale: Streptococcus pneumoniae is the most common pathogen
associated with community-acquired pneumonia. Other pathogens may
be involved, but this is the most frequent cause.
6. A nurse is caring for a client with a history of asthma who is
admitted with shortness of breath and wheezing. The nurse should
assess for which of the following first?
A. Oxygen saturation level
B. Peak flow readings
C. Breath sounds
D. Arterial blood gases
Answer: C. Breath sounds.
Rationale: The most important assessment for a client with asthma who
is wheezing and short of breath is evaluating breath sounds. This can
help determine the severity of the bronchospasm and whether there is
a need for urgent intervention.
