1. Which of the following is the most important nursing intervention
for a client with a new diagnosis of diabetes mellitus type 1?
A) Administer prescribed insulin
B) Provide education about blood glucose monitoring
C) Monitor the client’s blood pressure regularly
D) Encourage fluid intake
Answer: B) Provide education about blood glucose monitoring
Rationale: Education on blood glucose monitoring is essential to help
the client manage their diabetes. Monitoring their glucose levels is
crucial for understanding how food, exercise, and insulin affect their
blood sugar levels. While insulin administration (A) and fluid intake (D)
are important, the most crucial intervention at the beginning is ensuring
the client can monitor their blood sugar.
2. A client with chronic kidney disease (CKD) has a serum potassium
level of 6.5 mEq/L. What action should the nurse take?
A) Administer potassium chloride supplements
B) Offer foods high in potassium
C) Notify the healthcare provider immediately
D) Perform a 12-lead electrocardiogram (ECG)
Answer: C) Notify the healthcare provider immediately
Rationale: A potassium level of 6.5 mEq/L is above the normal range
(3.5-5.0 mEq/L), indicating hyperkalemia. Hyperkalemia can lead to life-
threatening arrhythmias. The nurse should immediately notify the
healthcare provider to manage this emergency situation, potentially
through the use of medications or other interventions to lower
potassium.
,3. A patient who has undergone a hip replacement surgery suddenly
develops shortness of breath, tachycardia, and chest pain. What is the
nurse’s priority action?
A) Administer pain medications
B) Position the patient in a low Fowler’s position
C) Prepare the patient for a chest X-ray
D) Assess the patient’s oxygen saturation level
Answer: D) Assess the patient’s oxygen saturation level
Rationale: The patient is exhibiting signs of a potential pulmonary
embolism (PE), including shortness of breath, tachycardia, and chest
pain. The first action should be to assess the oxygen saturation level to
determine if the patient requires immediate oxygen therapy and to
assess the severity of the situation.
4. A client is admitted with acute pancreatitis. The nurse understands
that which of the following is a common cause of this condition?
A) Gallstones
B) Kidney failure
C) Hyperthyroidism
D) Peptic ulcer disease
Answer: A) Gallstones
Rationale: Gallstones are one of the most common causes of acute
pancreatitis. The stones can block the bile duct, leading to inflammation
of the pancreas. Kidney failure (B), hyperthyroidism (C), and peptic ulcer
disease (D) are not typically associated with pancreatitis.
, 5. A client with cirrhosis of the liver is at risk for which of the following
complications?
A) Hypoglycemia
B) Hepatic encephalopathy
C) Acute kidney injury
D) Hypercalcemia
Answer: B) Hepatic encephalopathy
Rationale: Hepatic encephalopathy is a complication of cirrhosis caused
by the accumulation of toxins, such as ammonia, in the brain. This can
result in cognitive and neurological changes. Hypoglycemia (A) and
hypercalcemia (D) are not common complications of cirrhosis. Acute
kidney injury (C) can occur, but it is not the most common complication.
6. A nurse is caring for a client who is receiving chemotherapy and has
developed neutropenia. What should the nurse include in the care
plan?
A) Place the client in a private room
B) Administer a flu vaccine
C) Encourage raw fruits and vegetables
D) Maintain the client’s temperature above 101°F
Answer: A) Place the client in a private room
Rationale: Neutropenia, a low white blood cell count, increases the risk
of infection. Placing the client in a private room reduces the risk of
exposure to pathogens. The nurse should avoid administering vaccines
or encouraging raw fruits and vegetables (B and C) since these could
expose the client to pathogens. Keeping the temperature above 101°F
for a client with a new diagnosis of diabetes mellitus type 1?
A) Administer prescribed insulin
B) Provide education about blood glucose monitoring
C) Monitor the client’s blood pressure regularly
D) Encourage fluid intake
Answer: B) Provide education about blood glucose monitoring
Rationale: Education on blood glucose monitoring is essential to help
the client manage their diabetes. Monitoring their glucose levels is
crucial for understanding how food, exercise, and insulin affect their
blood sugar levels. While insulin administration (A) and fluid intake (D)
are important, the most crucial intervention at the beginning is ensuring
the client can monitor their blood sugar.
2. A client with chronic kidney disease (CKD) has a serum potassium
level of 6.5 mEq/L. What action should the nurse take?
A) Administer potassium chloride supplements
B) Offer foods high in potassium
C) Notify the healthcare provider immediately
D) Perform a 12-lead electrocardiogram (ECG)
Answer: C) Notify the healthcare provider immediately
Rationale: A potassium level of 6.5 mEq/L is above the normal range
(3.5-5.0 mEq/L), indicating hyperkalemia. Hyperkalemia can lead to life-
threatening arrhythmias. The nurse should immediately notify the
healthcare provider to manage this emergency situation, potentially
through the use of medications or other interventions to lower
potassium.
,3. A patient who has undergone a hip replacement surgery suddenly
develops shortness of breath, tachycardia, and chest pain. What is the
nurse’s priority action?
A) Administer pain medications
B) Position the patient in a low Fowler’s position
C) Prepare the patient for a chest X-ray
D) Assess the patient’s oxygen saturation level
Answer: D) Assess the patient’s oxygen saturation level
Rationale: The patient is exhibiting signs of a potential pulmonary
embolism (PE), including shortness of breath, tachycardia, and chest
pain. The first action should be to assess the oxygen saturation level to
determine if the patient requires immediate oxygen therapy and to
assess the severity of the situation.
4. A client is admitted with acute pancreatitis. The nurse understands
that which of the following is a common cause of this condition?
A) Gallstones
B) Kidney failure
C) Hyperthyroidism
D) Peptic ulcer disease
Answer: A) Gallstones
Rationale: Gallstones are one of the most common causes of acute
pancreatitis. The stones can block the bile duct, leading to inflammation
of the pancreas. Kidney failure (B), hyperthyroidism (C), and peptic ulcer
disease (D) are not typically associated with pancreatitis.
, 5. A client with cirrhosis of the liver is at risk for which of the following
complications?
A) Hypoglycemia
B) Hepatic encephalopathy
C) Acute kidney injury
D) Hypercalcemia
Answer: B) Hepatic encephalopathy
Rationale: Hepatic encephalopathy is a complication of cirrhosis caused
by the accumulation of toxins, such as ammonia, in the brain. This can
result in cognitive and neurological changes. Hypoglycemia (A) and
hypercalcemia (D) are not common complications of cirrhosis. Acute
kidney injury (C) can occur, but it is not the most common complication.
6. A nurse is caring for a client who is receiving chemotherapy and has
developed neutropenia. What should the nurse include in the care
plan?
A) Place the client in a private room
B) Administer a flu vaccine
C) Encourage raw fruits and vegetables
D) Maintain the client’s temperature above 101°F
Answer: A) Place the client in a private room
Rationale: Neutropenia, a low white blood cell count, increases the risk
of infection. Placing the client in a private room reduces the risk of
exposure to pathogens. The nurse should avoid administering vaccines
or encouraging raw fruits and vegetables (B and C) since these could
expose the client to pathogens. Keeping the temperature above 101°F
