Answers | Latest Version | 2025/2026 |
Correct & Verified
A client with chronic kidney disease has lab results: potassium 6.3 mEq/L. Which action is the
priority?
A. Encourage fluids
B. Restrict protein
✔✔C. Place on cardiac monitor
D. Monitor urine output
A client with COPD has oxygen ordered at 4 L/min via nasal cannula. Which intervention is
most important?
A. Apply humidifier
✔✔B. Titrate oxygen to maintain 88–92% saturation
C. Encourage frequent coughing
D. Increase oxygen if patient is anxious
A nurse is preparing to administer packed red blood cells. Which action prevents transfusion
reaction?
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,A. Monitor blood pressure after infusion
B. Use a 24-gauge IV catheter
✔✔C. Verify blood product with another nurse
D. Infuse over 6 hours
A client with pneumonia reports pleuritic chest pain. Which intervention provides the most
relief?
A. Ambulate every hour
✔✔B. Splint the chest during coughing
C. Restrict fluids
D. Place in Trendelenburg position
A client is prescribed lisinopril. Which adverse effect requires immediate action?
A. Dry cough
B. Dizziness
✔✔C. Swelling of lips and tongue
D. Fatigue
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,A client with cirrhosis has abdominal distension and shortness of breath. Which intervention
should the nurse perform first?
A. Administer diuretic
✔✔B. Measure abdominal girth and assess respiratory status
C. Place on fluid restriction
D. Prepare for liver biopsy
A postpartum client is experiencing heavy vaginal bleeding. Which action should the nurse
perform first?
A. Call the obstetrician
✔✔B. Massage the fundus
C. Insert a urinary catheter
D. Administer an oxytocic drug
A client is receiving heparin infusion. Which lab value should be monitored?
A. INR
✔✔B. aPTT
C. Hematocrit
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, D. Hemoglobin A1C
A nurse is teaching a client about levothyroxine. Which statement indicates correct
understanding?
A. “I should take this medication with milk.”
✔✔B. “I should take it in the morning before breakfast.”
C. “I can stop taking this medication once I feel better.”
D. “I should expect weight gain with this medication.”
A nurse is assessing a client with schizophrenia. Which finding requires immediate intervention?
A. Flat affect
✔✔B. Command hallucinations
C. Social withdrawal
D. Poor grooming
A client with a chest tube becomes suddenly short of breath and has tracheal deviation. What
complication is suspected?
A. Fluid overload
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