Answers | Latest Version | 2025/2026 |
Correct & Verified
A nurse is caring for a client with heart failure who reports sudden shortness of breath. Which
action should the nurse take first?
A. Notify the healthcare provider
✔✔B. Place the client in high Fowler’s position
C. Administer a PRN analgesic
D. Encourage the client to ambulate
A nurse is reviewing lab results for a client receiving chemotherapy. Which finding should the
nurse report immediately?
A. Hemoglobin 11.2 g/dL
✔✔B. Absolute neutrophil count 400/mm³
C. Platelet count 160,000/mm³
D. White blood cell count 5,000/mm³
A client with type 1 diabetes reports nausea and increased thirst. Which assessment is most
important?
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,A. Blood pressure
✔✔B. Blood glucose level
C. Daily weight
D. Capillary refill
A nurse is preparing to administer blood to a client. Which action is most important to reduce the
risk of a transfusion reaction?
✔✔A. Verify client identification with another nurse
B. Pre-medicate the client with acetaminophen
C. Warm the blood prior to administration
D. Monitor vital signs every 30 minutes
A nurse is caring for a client with COPD. Which oxygen delivery device is most appropriate?
A. Non-rebreather mask at 15 L/min
B. Simple face mask at 8 L/min
✔✔C. Nasal cannula at 2 L/min
D. Venturi mask at 50%
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,A nurse is teaching a client about warfarin therapy. Which statement indicates understanding?
A. “I will eat more green leafy vegetables.”
✔✔B. “I will have my INR checked regularly.”
C. “I will take aspirin for headaches.”
D. “I can stop taking the medication when I feel better.”
A nurse is assessing a client with a chest tube. Which finding requires immediate intervention?
A. Occasional bubbling in the water seal chamber
✔✔B. Continuous bubbling in the water seal chamber
C. Drainage of 80 mL over 4 hours
D. Fluctuation of water level with respirations
A nurse is caring for a client who is postoperative following abdominal surgery. Which
intervention helps prevent atelectasis?
A. Encourage bed rest
B. Limit fluid intake
✔✔C. Use incentive spirometer hourly
D. Apply abdominal binder tightly
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, A nurse is caring for a client with suspected meningitis. Which action should the nurse take first?
✔✔A. Place the client in droplet precautions
B. Administer IV antibiotics
C. Assess level of consciousness
D. Prepare the client for lumbar puncture
A nurse is teaching a client about a new prescription for digoxin. Which statement indicates the
client understands the teaching?
A. “I should take my pulse once a week.”
✔✔B. “I should hold the medication if my pulse is below 60.”
C. “I can double my dose if I miss one.”
D. “I should take this medication with antacids.”
A nurse is reviewing discharge instructions with a client with heart failure. Which food choice
shows correct understanding?
A. Canned soup
✔✔B. Fresh fruit salad
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