1. Question:
A nurse is caring for a client with heart failure. Which of the following
should the nurse prioritize in the plan of care?
• A) Monitor intake and output.
• B) Encourage the client to take a deep breath.
• C) Provide a low-sodium diet.
• D) Promote increased physical activity.
Answer: A) Monitor intake and output.
Rationale: Monitoring intake and output is crucial in clients with heart
failure to assess fluid retention and prevent fluid overload. Although a
low-sodium diet (C) and deep breathing (B) are also important, the
priority is fluid balance.
2. Question:
A nurse is caring for a client with chronic renal failure. Which of the
following lab values is most likely to be elevated in this client?
• A) Hemoglobin
• B) Sodium
• C) Potassium
• D) Albumin
Answer: C) Potassium
Rationale: In chronic renal failure, the kidneys' ability to excrete
potassium is impaired, leading to hyperkalemia. Sodium (B) and
,albumin (D) may be normal or low, and hemoglobin (A) is usually low
due to impaired erythropoiesis.
3. Question:
A client is admitted with a suspected stroke. Which of the following
actions should the nurse take first?
• A) Assess the client’s mental status.
• B) Administer oxygen.
• C) Obtain a blood pressure reading.
• D) Initiate an intravenous line.
Answer: B) Administer oxygen.
Rationale: Oxygen is administered first to ensure adequate brain
oxygenation, which is essential in stroke patients. Other actions, such as
assessing mental status or obtaining a blood pressure reading, are
important but secondary.
4. Question:
A nurse is educating a client with newly diagnosed Type 2 Diabetes
Mellitus. The nurse explains the importance of which of the following to
prevent complications?
• A) Restricting carbohydrate intake completely.
• B) Eating regular, balanced meals.
• C) Taking insulin at night only.
• D) Limiting fluid intake to prevent kidney damage.
,Answer: B) Eating regular, balanced meals.
Rationale: Clients with Type 2 Diabetes need to maintain a stable blood
sugar level, which can be achieved by eating regular, balanced meals.
Restricting carbohydrates completely (A) is not recommended, and
insulin should be taken as prescribed, not based on the time of day (C).
Limiting fluid intake (D) is unnecessary and may contribute to
dehydration.
5. Question:
A nurse is caring for a postoperative client who has a PCA (patient-
controlled analgesia) pump. The nurse understands that the primary
advantage of PCA is:
• A) The client is less likely to experience respiratory depression.
• B) The client is able to administer pain medication as needed.
• C) The nurse can manage the client’s pain more effectively.
• D) The client will not need any additional pain medications.
Answer: B) The client is able to administer pain medication as needed.
Rationale: The primary advantage of PCA is that it allows the client to
control their own pain relief, administering medication as needed
within prescribed limits. The nurse still monitors the client, but the key
benefit is patient autonomy.
6. Question:
A nurse is caring for a client with pneumonia. The nurse expects to find
which of the following on the physical assessment?
, • A) Bradycardia
• B) Increased breath sounds
• C) Hypoxemia
• D) Hypotension
Answer: C) Hypoxemia
Rationale: Pneumonia often causes hypoxemia due to impaired gas
exchange. Breath sounds may be decreased, and tachycardia (not
bradycardia) is typically observed. Hypotension is not a common finding
in pneumonia unless there is sepsis.
7. Question:
A client who has chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. The nurse should monitor the client for which
of the following complications?
• A) Hyperglycemia
• B) Oxygen toxicity
• C) Hypotension
• D) Electrolyte imbalance
Answer: B) Oxygen toxicity
Rationale: Clients with COPD are at risk for oxygen toxicity when high
levels of oxygen are administered for extended periods. Hyperglycemia
(A) is not directly related to oxygen therapy, and hypotension (C) is not
commonly seen with oxygen therapy.
A nurse is caring for a client with heart failure. Which of the following
should the nurse prioritize in the plan of care?
• A) Monitor intake and output.
• B) Encourage the client to take a deep breath.
• C) Provide a low-sodium diet.
• D) Promote increased physical activity.
Answer: A) Monitor intake and output.
Rationale: Monitoring intake and output is crucial in clients with heart
failure to assess fluid retention and prevent fluid overload. Although a
low-sodium diet (C) and deep breathing (B) are also important, the
priority is fluid balance.
2. Question:
A nurse is caring for a client with chronic renal failure. Which of the
following lab values is most likely to be elevated in this client?
• A) Hemoglobin
• B) Sodium
• C) Potassium
• D) Albumin
Answer: C) Potassium
Rationale: In chronic renal failure, the kidneys' ability to excrete
potassium is impaired, leading to hyperkalemia. Sodium (B) and
,albumin (D) may be normal or low, and hemoglobin (A) is usually low
due to impaired erythropoiesis.
3. Question:
A client is admitted with a suspected stroke. Which of the following
actions should the nurse take first?
• A) Assess the client’s mental status.
• B) Administer oxygen.
• C) Obtain a blood pressure reading.
• D) Initiate an intravenous line.
Answer: B) Administer oxygen.
Rationale: Oxygen is administered first to ensure adequate brain
oxygenation, which is essential in stroke patients. Other actions, such as
assessing mental status or obtaining a blood pressure reading, are
important but secondary.
4. Question:
A nurse is educating a client with newly diagnosed Type 2 Diabetes
Mellitus. The nurse explains the importance of which of the following to
prevent complications?
• A) Restricting carbohydrate intake completely.
• B) Eating regular, balanced meals.
• C) Taking insulin at night only.
• D) Limiting fluid intake to prevent kidney damage.
,Answer: B) Eating regular, balanced meals.
Rationale: Clients with Type 2 Diabetes need to maintain a stable blood
sugar level, which can be achieved by eating regular, balanced meals.
Restricting carbohydrates completely (A) is not recommended, and
insulin should be taken as prescribed, not based on the time of day (C).
Limiting fluid intake (D) is unnecessary and may contribute to
dehydration.
5. Question:
A nurse is caring for a postoperative client who has a PCA (patient-
controlled analgesia) pump. The nurse understands that the primary
advantage of PCA is:
• A) The client is less likely to experience respiratory depression.
• B) The client is able to administer pain medication as needed.
• C) The nurse can manage the client’s pain more effectively.
• D) The client will not need any additional pain medications.
Answer: B) The client is able to administer pain medication as needed.
Rationale: The primary advantage of PCA is that it allows the client to
control their own pain relief, administering medication as needed
within prescribed limits. The nurse still monitors the client, but the key
benefit is patient autonomy.
6. Question:
A nurse is caring for a client with pneumonia. The nurse expects to find
which of the following on the physical assessment?
, • A) Bradycardia
• B) Increased breath sounds
• C) Hypoxemia
• D) Hypotension
Answer: C) Hypoxemia
Rationale: Pneumonia often causes hypoxemia due to impaired gas
exchange. Breath sounds may be decreased, and tachycardia (not
bradycardia) is typically observed. Hypotension is not a common finding
in pneumonia unless there is sepsis.
7. Question:
A client who has chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. The nurse should monitor the client for which
of the following complications?
• A) Hyperglycemia
• B) Oxygen toxicity
• C) Hypotension
• D) Electrolyte imbalance
Answer: B) Oxygen toxicity
Rationale: Clients with COPD are at risk for oxygen toxicity when high
levels of oxygen are administered for extended periods. Hyperglycemia
(A) is not directly related to oxygen therapy, and hypotension (C) is not
commonly seen with oxygen therapy.
