and Answers | Latest Version |
2025/2026 | Correct & Verified
A client with pneumonia has a fever of 102°F and shortness of breath. What is the nurse’s first
action?
A. Encourage coughing and deep breathing
✔✔B. Administer oxygen as prescribed
C. Obtain a sputum culture
D. Call the provider
A client receiving IV vancomycin reports redness and itching at the infusion site. What should
the nurse do first?
A. Stop the infusion immediately
B. Apply a cold compress
✔✔C. Slow the infusion rate and monitor
D. Administer diphenhydramine
A client with type 2 diabetes reports fatigue and frequent urination. Which lab result requires
immediate action?
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,A. Sodium 138 mEq/L
✔✔B. Glucose 450 mg/dL
C. Potassium 4.0 mEq/L
D. Hemoglobin 14 g/dL
A nurse is teaching a client about dietary management of hypertension. Which statement
indicates understanding?
A. “I will add more salt to my meals.”
✔✔B. “I will limit my sodium intake and read food labels.”
C. “I should avoid fruits and vegetables.”
D. “I don’t need to check my blood pressure at home.”
A client prescribed digoxin reports nausea and blurred vision. What is the nurse’s priority action?
A. Administer the next scheduled dose
✔✔B. Hold the medication and notify the provider
C. Increase fluid intake
D. Encourage exercise
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,A nurse is caring for a client with COPD who has increased shortness of breath and wheezing.
Which action is priority?
A. Encourage deep breathing exercises
✔✔B. Administer prescribed bronchodilator
C. Obtain a chest X-ray
D. Call the respiratory therapist
A client is scheduled for a colonoscopy. Which teaching is most important before the procedure?
A. Avoid drinking fluids before the procedure
B. Eat a high-fiber diet the day before
✔✔C. Complete bowel prep as instructed
D. Avoid all medications permanently
A nurse is monitoring a client receiving TPN. Which finding requires immediate intervention?
A. Slight increase in blood glucose
B. Mild nausea
✔✔C. Redness or swelling at the IV site
D. Normal urine output
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, A postpartum client reports heavy bleeding and a firm uterus. What should the nurse do first?
A. Call the provider
B. Monitor vital signs
✔✔C. Massage the fundus
D. Encourage ambulation
A client with heart failure reports sudden weight gain of 3 pounds in 24 hours. What is the
nurse’s priority action?
A. Restrict fluid intake
✔✔B. Notify the healthcare provider
C. Increase diuretic dose without instruction
D. Encourage exercise
A client with a tracheostomy develops sudden respiratory distress. What is the nurse’s first
action?
A. Call respiratory therapy
✔✔B. Suction the tracheostomy
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