and Answers | Latest Version | 2025/2026
| Correct & Verified
A client reports sudden onset of severe headache and blurred vision. What is the nurse’s priority
action?
A. Offer pain medication
✔✔B. Assess blood pressure and neurological status
C. Encourage rest in a dark room
D. Notify the healthcare provider
A client with pneumonia has oxygen saturation of 88% on room air. Which action should the
nurse take first?
A. Call respiratory therapy
✔✔B. Apply supplemental oxygen and reassess
C. Encourage coughing and deep breathing
D. Place the client in Trendelenburg position
A nurse is teaching a client about a low-sodium diet. Which food choice indicates correct
understanding?
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,A. Canned soup
✔✔B. Fresh fruit
C. Processed cheese
D. Pickles
A client with a history of heart failure presents with sudden weight gain and edema. What is the
nurse’s priority action?
A. Restrict fluid intake
✔✔B. Assess lung sounds and vital signs
C. Administer diuretic as prescribed
D. Encourage bedrest
A nurse is reviewing labs for a client with chronic kidney disease. Which result requires
immediate action?
A. BUN 28 mg/dL
B. Calcium 8.5 mg/dL
✔✔C. Potassium 6.4 mEq/L
D. Hemoglobin 10 g/dL
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,A client receiving heparin develops bruising and gum bleeding. What should the nurse do first?
A. Continue therapy and monitor
B. Hold the next dose
✔✔C. Notify the healthcare provider
D. Apply pressure to bruised areas
A nurse is teaching a client about metformin. Which statement indicates understanding?
A. “I will skip doses if I feel dizzy.”
✔✔B. “I will take this medication with meals.”
C. “I will double the dose if I forget once.”
D. “I will avoid all fruits while taking this medication.”
A client with COPD is short of breath and has a productive cough. Which nursing intervention is
most effective?
A. Encourage bedrest
✔✔B. Promote frequent coughing and hydration
C. Limit fluid intake
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, D. Keep in supine position
A nurse is preparing to administer IV potassium. Which guideline is correct?
A. Give IV push rapidly
✔✔B. Dilute and infuse slowly with a pump
C. Administer only if urine output <10 mL/hr
D. Mix with dextrose and give rapidly
A client with a new tracheostomy has thick secretions. Which intervention should the nurse
perform first?
A. Call respiratory therapy
✔✔B. Suction the tracheostomy
C. Increase oxygen flow
D. Encourage coughing
A client with type 2 diabetes has fasting blood glucose of 220 mg/dL. Which action is
appropriate?
A. Administer insulin as prescribed ✔✔
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