1. Which of the following is the most important nursing intervention for a patient
who is receiving a blood transfusion and begins experiencing chills, fever, and
anxiety?
A. Stop the transfusion immediately and call the healthcare provider.
B. Increase the rate of the transfusion to alleviate symptoms.
C. Administer acetaminophen and continue the transfusion.
D. Administer a sedative to calm the patient.
Answer: A. Stop the transfusion immediately and call the healthcare provider.
Rationale: The symptoms suggest a possible blood transfusion reaction. Stopping the
transfusion immediately is the priority action, followed by notifying the healthcare provider to
manage the reaction appropriately.
2. A nurse is caring for a patient who is post-operative following a
cholecystectomy. Which of the following should the nurse prioritize during the
immediate post-operative period?
A. Ensuring the patient is consuming a high-fat diet.
B. Monitoring for signs of infection at the incision site.
C. Encouraging deep breathing and coughing exercises.
D. Administering pain medication only if the patient complains of severe pain.
Answer: C. Encouraging deep breathing and coughing exercises.
Rationale: Preventing respiratory complications, such as pneumonia, is a priority after surgery.
Encouraging deep breathing and coughing exercises helps to expand the lungs and clear
secretions.
3. A client with chronic obstructive pulmonary disease (COPD) is admitted with
increased shortness of breath. What is the most important action for the nurse to
take first?
A. Administer supplemental oxygen.
B. Assess the client’s respiratory rate and breath sounds.
C. Notify the healthcare provider.
D. Administer a bronchodilator as prescribed.
Answer: B. Assess the client’s respiratory rate and breath sounds.
,Rationale: The first step in managing an exacerbation of COPD is assessing the patient's current
respiratory status, including rate and breath sounds. This will guide further interventions like
oxygen or bronchodilators.
4. A nurse is caring for a client who has had a stroke and is experiencing
dysphagia. Which of the following actions should the nurse take to prevent
aspiration?
A. Place the patient in a supine position during meals.
B. Offer food in large bites to encourage quicker swallowing.
C. Encourage the patient to drink liquids quickly between bites.
D. Position the patient upright during meals and offer small, frequent bites.
Answer: D. Position the patient upright during meals and offer small, frequent bites.
Rationale: For patients with dysphagia, positioning them upright promotes safe swallowing, and
offering small, frequent bites reduces the risk of aspiration.
5. A patient is being treated for dehydration. Which of the following findings
would indicate improvement in the patient's condition?
A. Increased blood pressure.
B. Decreased heart rate.
C. Increased urine output.
D. Increased specific gravity of urine.
Answer: C. Increased urine output.
Rationale: Increased urine output is an indication that the body is adequately hydrated and fluid
balance is improving.
6. Which of the following is the most appropriate action when caring for a
patient who is receiving an IV infusion of potassium chloride (KCl)?
A. Monitor the patient's potassium level every day.
B. Infuse the KCl solution rapidly to correct the deficit quickly.
C. Ensure that the IV site is patent and check for signs of infiltration.
D. Do not administer KCl if the patient’s potassium level is elevated.
, Answer: C. Ensure that the IV site is patent and check for signs of infiltration.
Rationale: Potassium chloride should be administered cautiously because it can cause severe
irritation to veins. It is important to monitor the IV site to prevent infiltration or extravasation.
7. A nurse is caring for a patient with congestive heart failure. Which of the
following symptoms indicates the need for immediate intervention?
A. Shortness of breath with activity.
B. Weight gain of 2 kg (4.4 lb) in 24 hours.
C. Mild ankle edema.
D. Slight cough with clear sputum.
Answer: B. Weight gain of 2 kg (4.4 lb) in 24 hours.
Rationale: A rapid weight gain of more than 1 kg (2.2 lb) per day is a sign of fluid retention and
may indicate worsening heart failure, requiring immediate intervention.
8. Which of the following findings should a nurse expect in a patient with
hyperthyroidism?
A. Weight gain, bradycardia, cold intolerance.
B. Increased appetite, weight loss, heat intolerance.
C. Cold extremities, constipation, and fatigue.
D. Dry skin, hair loss, and sensitivity to cold.
Answer: B. Increased appetite, weight loss, heat intolerance.
Rationale: Hyperthyroidism causes an increased metabolic rate, leading to symptoms such as
weight loss, increased appetite, and heat intolerance.
9. A nurse is caring for a patient who is on strict bed rest and has a Foley
catheter in place. What is the primary concern regarding this patient’s care?
A. Risk of developing pressure ulcers.
B. Risk of urinary tract infection (UTI).
C. Risk of deep vein thrombosis (DVT).
D. Risk of electrolyte imbalances.
who is receiving a blood transfusion and begins experiencing chills, fever, and
anxiety?
A. Stop the transfusion immediately and call the healthcare provider.
B. Increase the rate of the transfusion to alleviate symptoms.
C. Administer acetaminophen and continue the transfusion.
D. Administer a sedative to calm the patient.
Answer: A. Stop the transfusion immediately and call the healthcare provider.
Rationale: The symptoms suggest a possible blood transfusion reaction. Stopping the
transfusion immediately is the priority action, followed by notifying the healthcare provider to
manage the reaction appropriately.
2. A nurse is caring for a patient who is post-operative following a
cholecystectomy. Which of the following should the nurse prioritize during the
immediate post-operative period?
A. Ensuring the patient is consuming a high-fat diet.
B. Monitoring for signs of infection at the incision site.
C. Encouraging deep breathing and coughing exercises.
D. Administering pain medication only if the patient complains of severe pain.
Answer: C. Encouraging deep breathing and coughing exercises.
Rationale: Preventing respiratory complications, such as pneumonia, is a priority after surgery.
Encouraging deep breathing and coughing exercises helps to expand the lungs and clear
secretions.
3. A client with chronic obstructive pulmonary disease (COPD) is admitted with
increased shortness of breath. What is the most important action for the nurse to
take first?
A. Administer supplemental oxygen.
B. Assess the client’s respiratory rate and breath sounds.
C. Notify the healthcare provider.
D. Administer a bronchodilator as prescribed.
Answer: B. Assess the client’s respiratory rate and breath sounds.
,Rationale: The first step in managing an exacerbation of COPD is assessing the patient's current
respiratory status, including rate and breath sounds. This will guide further interventions like
oxygen or bronchodilators.
4. A nurse is caring for a client who has had a stroke and is experiencing
dysphagia. Which of the following actions should the nurse take to prevent
aspiration?
A. Place the patient in a supine position during meals.
B. Offer food in large bites to encourage quicker swallowing.
C. Encourage the patient to drink liquids quickly between bites.
D. Position the patient upright during meals and offer small, frequent bites.
Answer: D. Position the patient upright during meals and offer small, frequent bites.
Rationale: For patients with dysphagia, positioning them upright promotes safe swallowing, and
offering small, frequent bites reduces the risk of aspiration.
5. A patient is being treated for dehydration. Which of the following findings
would indicate improvement in the patient's condition?
A. Increased blood pressure.
B. Decreased heart rate.
C. Increased urine output.
D. Increased specific gravity of urine.
Answer: C. Increased urine output.
Rationale: Increased urine output is an indication that the body is adequately hydrated and fluid
balance is improving.
6. Which of the following is the most appropriate action when caring for a
patient who is receiving an IV infusion of potassium chloride (KCl)?
A. Monitor the patient's potassium level every day.
B. Infuse the KCl solution rapidly to correct the deficit quickly.
C. Ensure that the IV site is patent and check for signs of infiltration.
D. Do not administer KCl if the patient’s potassium level is elevated.
, Answer: C. Ensure that the IV site is patent and check for signs of infiltration.
Rationale: Potassium chloride should be administered cautiously because it can cause severe
irritation to veins. It is important to monitor the IV site to prevent infiltration or extravasation.
7. A nurse is caring for a patient with congestive heart failure. Which of the
following symptoms indicates the need for immediate intervention?
A. Shortness of breath with activity.
B. Weight gain of 2 kg (4.4 lb) in 24 hours.
C. Mild ankle edema.
D. Slight cough with clear sputum.
Answer: B. Weight gain of 2 kg (4.4 lb) in 24 hours.
Rationale: A rapid weight gain of more than 1 kg (2.2 lb) per day is a sign of fluid retention and
may indicate worsening heart failure, requiring immediate intervention.
8. Which of the following findings should a nurse expect in a patient with
hyperthyroidism?
A. Weight gain, bradycardia, cold intolerance.
B. Increased appetite, weight loss, heat intolerance.
C. Cold extremities, constipation, and fatigue.
D. Dry skin, hair loss, and sensitivity to cold.
Answer: B. Increased appetite, weight loss, heat intolerance.
Rationale: Hyperthyroidism causes an increased metabolic rate, leading to symptoms such as
weight loss, increased appetite, and heat intolerance.
9. A nurse is caring for a patient who is on strict bed rest and has a Foley
catheter in place. What is the primary concern regarding this patient’s care?
A. Risk of developing pressure ulcers.
B. Risk of urinary tract infection (UTI).
C. Risk of deep vein thrombosis (DVT).
D. Risk of electrolyte imbalances.
