1. A nurse is caring for a client who is 36 weeks pregnant and
experiencing preeclampsia. Which of the following findings should the
nurse report immediately? a) Increased deep tendon reflexes b) Weight
gain of 1 pound per week c) Mild headache and blurry vision d) Urine
output of 500 mL in 24 hours
Answer: c) Mild headache and blurry vision
Rationale: A headache and blurry vision are signs of worsening
preeclampsia and could indicate the development of severe
hypertension, which requires immediate intervention.
2. A nurse is caring for a client who is postoperative and is refusing to
use the incentive spirometer. Which of the following should the nurse
do first? a) Administer pain medication to the client b) Explain the
importance of using the incentive spirometer to prevent pneumonia c)
Suggest that the client try deep breathing exercises instead d) Ask the
client to demonstrate the correct use of the incentive spirometer
Answer: b) Explain the importance of using the incentive spirometer to
prevent pneumonia
Rationale: Educating the client on the importance of using the
incentive spirometer to prevent complications like pneumonia is the
first step. It helps to explain why the intervention is necessary for their
recovery.
,3. A nurse is caring for a client with diabetes mellitus who is
experiencing hypoglycemia. Which of the following is the best
intervention? a) Administer insulin as prescribed b) Encourage the
client to drink a glass of water c) Provide the client with a snack
containing 15 grams of carbohydrates d) Have the client rest and
monitor their blood sugar every hour
Answer: c) Provide the client with a snack containing 15 grams of
carbohydrates
Rationale: Hypoglycemia is treated by providing a quick source of
glucose, such as a snack containing 15 grams of carbohydrates, to raise
the blood sugar to a safe level.
4. A nurse is caring for a client with chronic kidney disease (CKD).
Which of the following lab results is most concerning? a) Elevated
blood urea nitrogen (BUN) b) Elevated serum creatinine level c)
Decreased hemoglobin level d) Increased potassium level
Answer: d) Increased potassium level
Rationale: Elevated potassium levels are a critical concern in CKD, as
hyperkalemia can lead to life-threatening arrhythmias. The nurse
should prioritize monitoring and managing potassium levels in these
clients.
5. A nurse is caring for a client with pancreatitis. Which of the
following is most important to monitor for? a) Respiratory rate b)
Serum calcium levels c) Blood glucose levels d) Liver function tests
Answer: b) Serum calcium levels
, Rationale: Hypocalcemia is a common complication of pancreatitis. The
nurse should monitor calcium levels as part of the client's care to detect
this imbalance early.
6. A nurse is teaching a client with a new diagnosis of hypertension
about lifestyle modifications. Which of the following statements by the
client indicates understanding? a) "I will increase my intake of salt to
help regulate my blood pressure." b) "I will exercise for at least 30
minutes most days of the week." c) "I will stop drinking water and only
drink caffeinated beverages." d) "I will avoid eating foods high in fiber
to keep my blood pressure normal."
Answer: b) "I will exercise for at least 30 minutes most days of the
week."
Rationale: Regular exercise is an important lifestyle modification for
managing hypertension. It can help lower blood pressure and improve
overall cardiovascular health.
7. A client who has undergone a colonoscopy is ready for discharge.
Which of the following instructions should the nurse include in the
discharge teaching? a) "You can resume normal activities immediately."
b) "You should refrain from eating for the next 12 hours." c) "You may
experience mild cramping or bloating for a few hours." d) "Take a
laxative if you experience constipation within 24 hours."
Answer: c) "You may experience mild cramping or bloating for a few
hours."
Rationale: Mild cramping or bloating is a common side effect after a
colonoscopy due to air introduced into the colon during the procedure.
experiencing preeclampsia. Which of the following findings should the
nurse report immediately? a) Increased deep tendon reflexes b) Weight
gain of 1 pound per week c) Mild headache and blurry vision d) Urine
output of 500 mL in 24 hours
Answer: c) Mild headache and blurry vision
Rationale: A headache and blurry vision are signs of worsening
preeclampsia and could indicate the development of severe
hypertension, which requires immediate intervention.
2. A nurse is caring for a client who is postoperative and is refusing to
use the incentive spirometer. Which of the following should the nurse
do first? a) Administer pain medication to the client b) Explain the
importance of using the incentive spirometer to prevent pneumonia c)
Suggest that the client try deep breathing exercises instead d) Ask the
client to demonstrate the correct use of the incentive spirometer
Answer: b) Explain the importance of using the incentive spirometer to
prevent pneumonia
Rationale: Educating the client on the importance of using the
incentive spirometer to prevent complications like pneumonia is the
first step. It helps to explain why the intervention is necessary for their
recovery.
,3. A nurse is caring for a client with diabetes mellitus who is
experiencing hypoglycemia. Which of the following is the best
intervention? a) Administer insulin as prescribed b) Encourage the
client to drink a glass of water c) Provide the client with a snack
containing 15 grams of carbohydrates d) Have the client rest and
monitor their blood sugar every hour
Answer: c) Provide the client with a snack containing 15 grams of
carbohydrates
Rationale: Hypoglycemia is treated by providing a quick source of
glucose, such as a snack containing 15 grams of carbohydrates, to raise
the blood sugar to a safe level.
4. A nurse is caring for a client with chronic kidney disease (CKD).
Which of the following lab results is most concerning? a) Elevated
blood urea nitrogen (BUN) b) Elevated serum creatinine level c)
Decreased hemoglobin level d) Increased potassium level
Answer: d) Increased potassium level
Rationale: Elevated potassium levels are a critical concern in CKD, as
hyperkalemia can lead to life-threatening arrhythmias. The nurse
should prioritize monitoring and managing potassium levels in these
clients.
5. A nurse is caring for a client with pancreatitis. Which of the
following is most important to monitor for? a) Respiratory rate b)
Serum calcium levels c) Blood glucose levels d) Liver function tests
Answer: b) Serum calcium levels
, Rationale: Hypocalcemia is a common complication of pancreatitis. The
nurse should monitor calcium levels as part of the client's care to detect
this imbalance early.
6. A nurse is teaching a client with a new diagnosis of hypertension
about lifestyle modifications. Which of the following statements by the
client indicates understanding? a) "I will increase my intake of salt to
help regulate my blood pressure." b) "I will exercise for at least 30
minutes most days of the week." c) "I will stop drinking water and only
drink caffeinated beverages." d) "I will avoid eating foods high in fiber
to keep my blood pressure normal."
Answer: b) "I will exercise for at least 30 minutes most days of the
week."
Rationale: Regular exercise is an important lifestyle modification for
managing hypertension. It can help lower blood pressure and improve
overall cardiovascular health.
7. A client who has undergone a colonoscopy is ready for discharge.
Which of the following instructions should the nurse include in the
discharge teaching? a) "You can resume normal activities immediately."
b) "You should refrain from eating for the next 12 hours." c) "You may
experience mild cramping or bloating for a few hours." d) "Take a
laxative if you experience constipation within 24 hours."
Answer: c) "You may experience mild cramping or bloating for a few
hours."
Rationale: Mild cramping or bloating is a common side effect after a
colonoscopy due to air introduced into the colon during the procedure.
