Rationale) Questions and Answers |
Latest Version | 2025/2026 | Correct &
Verified
A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The nurse should
expect the oxygen saturation to be maintained at
A. 80% to 85%
B. 86% to 88%
✔✔C. 92% or greater
D. 100% at all times
A nurse is caring for a client receiving IV potassium. The nurse should monitor for
✔✔A. Cardiac arrhythmias
B. Increased urine output
C. Hypotension from fluid loss
D. Constipation
A postpartum client reports burning on urination. The nurse should first
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,A. Tell her to drink less fluid
✔✔B. Assess for urinary tract infection
C. Apply a warm compress to the abdomen
D. Encourage bed rest
A nurse is caring for a client with major depressive disorder. Which statement indicates
improvement?
A. “I still don’t want to be around anyone.”
✔✔B. “I am planning to attend my granddaughter’s birthday.”
C. “Nothing will ever change.”
D. “I feel hopeless most of the time.”
A nurse is caring for a client receiving total parenteral nutrition (TPN). The priority assessment is
✔✔A. Blood glucose level
B. Bowel sounds
C. Skin turgor
D. Urine color
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,A client with COPD becomes short of breath while ambulating. The nurse should first
✔✔A. Have the client sit and use pursed-lip breathing
B. Administer IV fluids
C. Increase oxygen to 6 L/min
D. Apply a cooling blanket
A nurse is teaching about oral contraceptives. Which finding requires immediate follow-up?
A. Occasional nausea
✔✔B. Severe calf pain
C. Breast tenderness
D. Mild weight gain
A nurse is caring for a client with suspected meningitis. The nurse should implement
A. Contact precautions
B. Droplet precautions only during procedures
✔✔C. Droplet precautions until antibiotics are started
D. Airborne precautions at all times
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, A nurse is reviewing medication orders for a child. Which prescription should be questioned?
✔✔A. Aspirin for a child with influenza
B. Acetaminophen for fever
C. Amoxicillin for ear infection
D. Albuterol for wheezing
A client with a chest tube accidentally disconnects from the drainage system. The nurse’s priority
action is to
A. Clamp the tube
✔✔B. Place the tube in sterile water
C. Call the healthcare provider immediately
D. Apply a dry dressing
A nurse is assessing a client after a thyroidectomy. Which finding requires immediate
intervention?
A. Hoarse voice
✔✔B. Respiratory distress and stridor
C. Sore throat
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