Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
What is the first step a nurse should take when assessing a client who is experiencing chest pain?
✔✔ The first step is to assess the client’s vital signs, including heart rate, blood pressure, and
oxygen saturation, while obtaining a detailed history of the pain.
How should a nurse prioritize interventions when caring for a client with a sudden onset of
shortness of breath?
✔✔ The nurse should first ensure that the client’s airway is clear, administer oxygen if needed,
and then assess the client’s vital signs and lung sounds.
What action should a nurse take when caring for a post-operative client with a history of deep
vein thrombosis (DVT) who reports sudden leg swelling and pain?
✔✔ The nurse should assess the affected leg for redness, warmth, and tenderness, elevate the
leg, and notify the healthcare provider immediately for further evaluation.
What is the best approach to handle a client who is refusing medication after a surgical
procedure?
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, ✔✔ The nurse should assess the reason for refusal, provide information about the benefits and
risks of the medication, and involve the healthcare provider if needed to address concerns.
What is the nurse’s role in identifying signs of infection in a post-operative client?
✔✔ The nurse should monitor for changes in vital signs, redness, swelling, warmth at the
surgical site, or the presence of purulent drainage and notify the healthcare provider if these signs
occur.
When a client presents with a decreased level of consciousness, what is the nurse’s initial
assessment?
✔✔ The nurse should assess the client’s airway, breathing, and circulation (ABCs), perform a
Glasgow Coma Scale (GCS) assessment, and determine if any immediate interventions are
needed.
What should a nurse do if a client with diabetes presents with a blood glucose level of 40 mg/dL?
✔✔ The nurse should immediately administer a fast-acting carbohydrate and reassess the client’s
blood glucose after 15 minutes to ensure the level has increased.
How should a nurse respond when a client begins to exhibit signs of acute anxiety and difficulty
breathing?
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