Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
What is the priority nursing action when a client develops sudden shortness of breath and chest
pain?
✔✔ Elevate the head of the bed and apply oxygen
What lab value should the nurse monitor for a client on warfarin therapy?
✔✔ INR
What is a key nursing consideration when administering a beta-blocker?
✔✔ Check the client’s blood pressure and heart rate before administration
What is the appropriate nursing action for a client experiencing a blood transfusion reaction?
✔✔ Stop the transfusion immediately and keep the IV line open with normal saline
What is a sign of digoxin toxicity in an older adult?
✔✔ Visual disturbances and bradycardia
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, What intervention can help prevent ventilator-associated pneumonia in intubated clients?
✔✔ Perform oral care every 2 hours
What should the nurse assess for in a client receiving opioids for pain management?
✔✔ Respiratory rate and level of consciousness
A client with heart failure is gaining 2 pounds in 24 hours. What should the nurse suspect?
✔✔ Fluid retention and possible worsening heart failure
What is the most reliable method for verifying the correct placement of a central venous
catheter?
✔✔ Chest X-ray
What electrolyte imbalance is most likely with prolonged vomiting?
✔✔ Hypokalemia
What is the priority nursing action for a client with a potassium level of 2.8 mEq/L?
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