1. A nurse is caring for a client with a history of hypertension
who is taking a
beta-blocker. Which of the following findings should the nurse
report to the
provider?
A. Blood pressure of 128/84 mmHg.
B. Apical pulse of 48 bpm.
C. Serum sodium level of 140 mEq/L.
D. Respiratory rate of 16 breaths per minute.
Answer: b) Apical pulse of 48 bpm.
Rationale: A heart rate below 50 bpm in a client taking a beta-
blocker is a concern, as it may
indicate bradycardia, which requires further evaluation and
potential adjustment of medication.
2. A nurse is caring for a client with a urinary tract infection
(UTI). Which of
the following statements by the client indicates a need for
further teaching?
A. "I should drink plenty of fluids."
B. "I will take my antibiotics until I feel better."
C. "I should wipe from front to back after using the toilet."
,D. "I will urinate when I feel the urge, even if it’s inconvenient."
Answer: b) "I will take my antibiotics until I feel better."
Rationale: The client should be instructed to complete the full
course of antibiotics, even if they
feel better, to prevent antibiotic resistance and recurrence of the
infection.
3. A nurse is caring for a client with a history of heart failure who
is receiving
digoxin. Which of the following findings should the nurse report
to the provider?
A. Apical pulse of 72 bpm
B. Serum potassium level of 3.2 mEq/L
C. Blood pressure of 110/70 mmHg
D. Respiratory rate of 18 breaths per minute
Answer: b) Serum potassium level of 3.2 mEq/L
Rationale: Low potassium levels increase the risk of digoxin
toxicity. The nurse should report a
potassium level of 3.2 mEq/L, which is below the normal range of
3.5-5.0 mEq/L.
4. A nurse is caring for a client with a history of alcohol use
disorder. Which of
the following findings should the nurse recognize as a sign of
alcohol
,withdrawal?
A. Hypotension
B. Seizures
C. Bradycardia
D. Drowsiness
Answer: b) Seizures
Rationale: Seizures are a serious complication of alcohol
withdrawal and require immediate
intervention.
5. A nurse is providing discharge teaching to a client who has a
new diagnosis of
type 2 diabetes mellitus. Which of the following statements by
the client indicates
A. need for further teaching?
A. "I will check my blood sugar levels at least once a day."
B. "I will take my insulin at the same time every day."
C. "I will eat meals at the same time each day to prevent blood
sugar fluctuations."
D. "I will only take insulin when I feel my blood sugar is high."
Answer: d) "I will only take insulin when I feel my blood sugar is
high."
Rationale: Insulin should be taken as prescribed by the provider,
regardless of the client's
, symptoms. The client should not wait until they feel their blood
sugar is high to administer
insulin.
6. A nurse is caring for a client who has a diagnosis of
hypothyroidism. Which
of the following symptoms should the nurse expect?
A. Increased heart rate.
B. Weight loss.
C. Cold intolerance.
D. Diarrhea.
Answer: c) Cold intolerance.
Rationale: Hypothyroidism typically results in symptoms such as
cold intolerance, weight gain,
and constipation due to the slowed metabolic rate.
7. A nurse is caring for a client who is experiencing a myocardial
infarction (MI).
Which of the following interventions should the nurse perform
first?
A. Administer morphine.
B. Administer oxygen.
C. Start an intravenous line.
D. Administer aspirin.
who is taking a
beta-blocker. Which of the following findings should the nurse
report to the
provider?
A. Blood pressure of 128/84 mmHg.
B. Apical pulse of 48 bpm.
C. Serum sodium level of 140 mEq/L.
D. Respiratory rate of 16 breaths per minute.
Answer: b) Apical pulse of 48 bpm.
Rationale: A heart rate below 50 bpm in a client taking a beta-
blocker is a concern, as it may
indicate bradycardia, which requires further evaluation and
potential adjustment of medication.
2. A nurse is caring for a client with a urinary tract infection
(UTI). Which of
the following statements by the client indicates a need for
further teaching?
A. "I should drink plenty of fluids."
B. "I will take my antibiotics until I feel better."
C. "I should wipe from front to back after using the toilet."
,D. "I will urinate when I feel the urge, even if it’s inconvenient."
Answer: b) "I will take my antibiotics until I feel better."
Rationale: The client should be instructed to complete the full
course of antibiotics, even if they
feel better, to prevent antibiotic resistance and recurrence of the
infection.
3. A nurse is caring for a client with a history of heart failure who
is receiving
digoxin. Which of the following findings should the nurse report
to the provider?
A. Apical pulse of 72 bpm
B. Serum potassium level of 3.2 mEq/L
C. Blood pressure of 110/70 mmHg
D. Respiratory rate of 18 breaths per minute
Answer: b) Serum potassium level of 3.2 mEq/L
Rationale: Low potassium levels increase the risk of digoxin
toxicity. The nurse should report a
potassium level of 3.2 mEq/L, which is below the normal range of
3.5-5.0 mEq/L.
4. A nurse is caring for a client with a history of alcohol use
disorder. Which of
the following findings should the nurse recognize as a sign of
alcohol
,withdrawal?
A. Hypotension
B. Seizures
C. Bradycardia
D. Drowsiness
Answer: b) Seizures
Rationale: Seizures are a serious complication of alcohol
withdrawal and require immediate
intervention.
5. A nurse is providing discharge teaching to a client who has a
new diagnosis of
type 2 diabetes mellitus. Which of the following statements by
the client indicates
A. need for further teaching?
A. "I will check my blood sugar levels at least once a day."
B. "I will take my insulin at the same time every day."
C. "I will eat meals at the same time each day to prevent blood
sugar fluctuations."
D. "I will only take insulin when I feel my blood sugar is high."
Answer: d) "I will only take insulin when I feel my blood sugar is
high."
Rationale: Insulin should be taken as prescribed by the provider,
regardless of the client's
, symptoms. The client should not wait until they feel their blood
sugar is high to administer
insulin.
6. A nurse is caring for a client who has a diagnosis of
hypothyroidism. Which
of the following symptoms should the nurse expect?
A. Increased heart rate.
B. Weight loss.
C. Cold intolerance.
D. Diarrhea.
Answer: c) Cold intolerance.
Rationale: Hypothyroidism typically results in symptoms such as
cold intolerance, weight gain,
and constipation due to the slowed metabolic rate.
7. A nurse is caring for a client who is experiencing a myocardial
infarction (MI).
Which of the following interventions should the nurse perform
first?
A. Administer morphine.
B. Administer oxygen.
C. Start an intravenous line.
D. Administer aspirin.
