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QUESTION 1:
A nurse is assessing a patient who has just undergone a total hip
replacement. Which of the following findings would be a priority for the
nurse to report to the healthcare provider?
A) The patient reports pain at the surgical site.
B) The patient has difficulty moving the affected leg.
C) The patient’s affected leg appears shorter than the other leg.
D) The patient has a temperature of 100.4°F (38°C).
CORRECT OPTION: C) The patient’s affected leg appears shorter than
the other leg.
RATIONALE This may indicate dislocation or improper alignment, which
requires immediate attention.
QUESTION 2:
A nurse is teaching a group of clients about the signs and symptoms of
hypoglycemia. Which statement by a client indicates a need for further
teaching?
A) "I should eat a snack if I feel shaky."
B) "Sweating and confusion are signs I need to watch for."
C) "I can treat it with insulin if it happens."
D) "I should carry glucose tablets with me."
CORRECT OPTION: C) "I can treat it with insulin if it happens."
RATIONALE Insulin can exacerbate hypoglycemia; clients should consume
carbohydrates instead.
QUESTION 3:
During a routine assessment, a nurse discovers that a patient has a heart
rate of 120 beats per minute and is complaining of palpitations. What is the
most appropriate nursing action?
,A) Document the findings and continue the assessment.
B) Administer a beta-blocker as prescribed.
C) Obtain a 12-lead ECG.
D) Encourage the patient to rest and relax.
CORRECT OPTION: C) Obtain a 12-lead ECG.
RATIONALE An ECG is necessary to assess the heart’s rhythm and
potential underlying issues.
QUESTION 4:
A nurse is caring for a client receiving chemotherapy who reports nausea.
Which intervention should the nurse implement first?
A) Administer antiemetic medication.
B) Ask the client to describe the nausea.
C) Provide ginger ale and crackers.
D) Schedule a follow-up appointment.
CORRECT OPTION: B) Ask the client to describe the nausea.
RATIONALE Understanding the nature of nausea can help tailor the
intervention effectively.
QUESTION 5:
A nurse is teaching a client with hypertension about dietary changes.
Which statement by the client indicates a need for further teaching?
A) "I will reduce my salt intake."
B) "I can eat more fruits and vegetables."
C) "I can continue to eat processed foods."
D) "I will limit my intake of saturated fats."
CORRECT OPTION: C) "I can continue to eat processed foods."
RATIONALE Processed foods often contain high levels of sodium, which
should be avoided.
QUESTION 6:
A nurse is assessing a patient with heart failure. Which finding would be
most concerning?
,A) Weight gain of 2 pounds in one week.
B) Increased shortness of breath with activity.
C) Mild edema in the ankles.
D) Fatigue during the day.
CORRECT OPTION: B) Increased shortness of breath with activity.
RATIONALE This may indicate worsening heart failure and requires
immediate attention.
QUESTION 7:
A nurse is providing discharge instructions to a patient with asthma. Which
statement by the patient indicates a need for further teaching?
A) "I should avoid my asthma triggers."
B) "I can use my rescue inhaler whenever I want."
C) "I need to take my long-term control medication daily."
D) "I will carry my inhaler with me at all times."
CORRECT OPTION: B) "I can use my rescue inhaler whenever I want."
RATIONALE The rescue inhaler should be used only as needed, not on a
regular schedule.
QUESTION 8:
A nurse is caring for a diabetic patient who is experiencing hypoglycemia.
What is the priority nursing intervention?
A) Administer glucose tablets.
B) Call the healthcare provider.
C) Provide a high-protein snack.
D) Offer water to drink.
CORRECT OPTION: A) Administer glucose tablets.
RATIONALE Treating hypoglycemia promptly is critical for patient safety.
QUESTION 9:
A nurse is evaluating a patient’s understanding of warfarin therapy. Which
statement by the patient indicates a need for further teaching?
, A) "I should have regular blood tests."
B) "I can take aspirin without consulting my doctor."
C) "I will avoid foods high in vitamin K."
D) "I need to report any unusual bleeding."
CORRECT OPTION: B) "I can take aspirin without consulting my doctor."
RATIONALE Aspirin can increase the risk of bleeding when taking warfarin.
QUESTION 10:
A nurse is caring for a patient with chronic obstructive pulmonary disease
(COPD). Which assessment finding would require immediate intervention?
A) Increased respiratory rate.
B) Use of accessory muscles for breathing.
C) Productive cough with clear sputum.
D) Oxygen saturation of 92%.
CORRECT OPTION: B) Use of accessory muscles for breathing.
RATIONALE This indicates respiratory distress and requires immediate
action.
QUESTION 11:
A nurse is planning care for a patient with a newly diagnosed peptic ulcer.
Which dietary intervention should be included in the plan?
A) Avoiding spicy foods.
B) Increasing caffeine intake.
C) Eating three large meals per day.
D) Consuming alcohol in moderation.
CORRECT OPTION: A) Avoiding spicy foods.
RATIONALE Spicy foods can irritate the gastric mucosa and worsen ulcer
symptoms.
QUESTION 12:
A nurse is assessing a child with suspected appendicitis. Which finding is
characteristic of this condition?