Which of the following statements about informed consent is correct?
A) It must always be obtained by a nurse.
B) It is not required for emergency procedures.
C) It requires the patient to sign a document without explanation.
D) It is only valid if the patient is under sedation.
Answer: B) It is not required for emergency procedures.
Explanation: In emergency situations where a patient is unable to provide consent, treatment may be provided without informed
consent to preserve life or prevent serious harm.
A client with heart failure is prescribed furosemide (Lasix). What is the most important electrolyte imbalance to monitor?
A) Hypercalcemia
B) Hypokalemia
C) Hypernatremia
D) Hypochloremia
Answer: B) Hypokalemia
Explanation: Furosemide is a loop diuretic that increases urine output and can lead to potassium loss, causing hypokalemia, which
may result in muscle weakness and cardiac arrhythmias.
A client with diabetes mellitus is experiencing hypoglycemia. Which symptom is most indicative of this condition?
A) Fruity breath odor
B) Excessive thirst
C) Cold, clammy skin
D) Frequent urination
Answer: C) Cold, clammy skin
Explanation: Hypoglycemia can cause symptoms such as sweating, pallor, dizziness, and clammy skin due to low blood sugar levels
affecting the nervous system.
,Which type of isolation precaution is required for a patient with tuberculosis (TB)?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions
Answer: C) Airborne precautions
Explanation: TB is an airborne disease that requires the use of an N95 respirator and a negative-pressure isolation room to prevent
the spread of infection.
The nurse is reinforcing teaching about digoxin (Lanoxin) therapy. Which statement by the client indicates a need for further
teaching?
A) “I should check my pulse before taking the medication.”
B) “If I experience nausea, I should take another dose.”
C) “I should report vision changes to my healthcare provider.”
D) “I need to monitor my potassium levels.”
Answer: B) “If I experience nausea, I should take another dose.”
Explanation: Nausea is a sign of digoxin toxicity. The client should report symptoms rather than taking an extra dose.
A nurse is caring for a client with a Foley catheter. How should the nurse prevent urinary tract infections (UTIs)?
A) Keep the drainage bag level with the bladder
B) Empty the drainage bag only when it is full
C) Clean the perineal area regularly
D) Clamp the catheter frequently to maintain bladder tone
Answer: C) Clean the perineal area regularly
Explanation: Proper perineal hygiene helps reduce the risk of catheter-associated urinary tract infections (CAUTIs).
,Which nursing intervention is most appropriate for a client with pneumonia?
A) Encourage fluid restriction
B) Encourage frequent deep breathing and coughing
C) Place the client in a supine position
D) Administer antihistamines as prescribed
Answer: B) Encourage frequent deep breathing and coughing
Explanation: Deep breathing and coughing help mobilize secretions, improve oxygenation, and prevent atelectasis in pneumonia
patients.
A nurse is monitoring a client receiving intravenous (IV) potassium chloride. Which finding requires immediate intervention?
A) Mild burning at the IV site
B) Serum potassium level of 4.0 mEq/L
C) Decreased urine output
D) Heart rate of 80 beats per minute
Answer: C) Decreased urine output
Explanation: Potassium is excreted by the kidneys, and decreased urine output can lead to hyperkalemia, which is life-threatening.
A client with COPD is receiving oxygen therapy. What is the most important nursing action?
A) Encourage deep breathing exercises
B) Increase oxygen flow rate as needed
C) Keep the client in a supine position
D) Administer bronchodilators after meals
Answer: A) Encourage deep breathing exercises
Explanation: Deep breathing helps improve lung expansion, prevent mucus buildup, and reduce dyspnea in COPD patients.
Which food should a client taking warfarin (Coumadin) avoid?
, A) Bananas
B) Spinach
C) Chicken
D) Rice
Answer: B) Spinach
Explanation: Spinach is high in vitamin K, which can counteract the effects of warfarin, increasing the risk of clot formation.
A nurse is assessing a client with Cushing’s syndrome. Which symptom is expected?
A) Hypotension
B) Moon face
C) Weight loss
D) Decreased blood glucose levels
Answer: B) Moon face
Explanation: Cushing’s syndrome results from excess cortisol, leading to fat redistribution, causing a round “moon face”
appearance.
A postpartum client is experiencing heavy vaginal bleeding. What is the nurse’s priority action?
A) Massage the fundus
B) Offer fluids
C) Place the client in a supine position
D) Administer a sedative
Answer: A) Massage the fundus
Explanation: Uterine atony is a common cause of postpartum hemorrhage, and fundal massage helps the uterus contract and reduce
bleeding.
Which action by the nurse can help prevent aspiration in a client with dysphagia?
A) It must always be obtained by a nurse.
B) It is not required for emergency procedures.
C) It requires the patient to sign a document without explanation.
D) It is only valid if the patient is under sedation.
Answer: B) It is not required for emergency procedures.
Explanation: In emergency situations where a patient is unable to provide consent, treatment may be provided without informed
consent to preserve life or prevent serious harm.
A client with heart failure is prescribed furosemide (Lasix). What is the most important electrolyte imbalance to monitor?
A) Hypercalcemia
B) Hypokalemia
C) Hypernatremia
D) Hypochloremia
Answer: B) Hypokalemia
Explanation: Furosemide is a loop diuretic that increases urine output and can lead to potassium loss, causing hypokalemia, which
may result in muscle weakness and cardiac arrhythmias.
A client with diabetes mellitus is experiencing hypoglycemia. Which symptom is most indicative of this condition?
A) Fruity breath odor
B) Excessive thirst
C) Cold, clammy skin
D) Frequent urination
Answer: C) Cold, clammy skin
Explanation: Hypoglycemia can cause symptoms such as sweating, pallor, dizziness, and clammy skin due to low blood sugar levels
affecting the nervous system.
,Which type of isolation precaution is required for a patient with tuberculosis (TB)?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions
Answer: C) Airborne precautions
Explanation: TB is an airborne disease that requires the use of an N95 respirator and a negative-pressure isolation room to prevent
the spread of infection.
The nurse is reinforcing teaching about digoxin (Lanoxin) therapy. Which statement by the client indicates a need for further
teaching?
A) “I should check my pulse before taking the medication.”
B) “If I experience nausea, I should take another dose.”
C) “I should report vision changes to my healthcare provider.”
D) “I need to monitor my potassium levels.”
Answer: B) “If I experience nausea, I should take another dose.”
Explanation: Nausea is a sign of digoxin toxicity. The client should report symptoms rather than taking an extra dose.
A nurse is caring for a client with a Foley catheter. How should the nurse prevent urinary tract infections (UTIs)?
A) Keep the drainage bag level with the bladder
B) Empty the drainage bag only when it is full
C) Clean the perineal area regularly
D) Clamp the catheter frequently to maintain bladder tone
Answer: C) Clean the perineal area regularly
Explanation: Proper perineal hygiene helps reduce the risk of catheter-associated urinary tract infections (CAUTIs).
,Which nursing intervention is most appropriate for a client with pneumonia?
A) Encourage fluid restriction
B) Encourage frequent deep breathing and coughing
C) Place the client in a supine position
D) Administer antihistamines as prescribed
Answer: B) Encourage frequent deep breathing and coughing
Explanation: Deep breathing and coughing help mobilize secretions, improve oxygenation, and prevent atelectasis in pneumonia
patients.
A nurse is monitoring a client receiving intravenous (IV) potassium chloride. Which finding requires immediate intervention?
A) Mild burning at the IV site
B) Serum potassium level of 4.0 mEq/L
C) Decreased urine output
D) Heart rate of 80 beats per minute
Answer: C) Decreased urine output
Explanation: Potassium is excreted by the kidneys, and decreased urine output can lead to hyperkalemia, which is life-threatening.
A client with COPD is receiving oxygen therapy. What is the most important nursing action?
A) Encourage deep breathing exercises
B) Increase oxygen flow rate as needed
C) Keep the client in a supine position
D) Administer bronchodilators after meals
Answer: A) Encourage deep breathing exercises
Explanation: Deep breathing helps improve lung expansion, prevent mucus buildup, and reduce dyspnea in COPD patients.
Which food should a client taking warfarin (Coumadin) avoid?
, A) Bananas
B) Spinach
C) Chicken
D) Rice
Answer: B) Spinach
Explanation: Spinach is high in vitamin K, which can counteract the effects of warfarin, increasing the risk of clot formation.
A nurse is assessing a client with Cushing’s syndrome. Which symptom is expected?
A) Hypotension
B) Moon face
C) Weight loss
D) Decreased blood glucose levels
Answer: B) Moon face
Explanation: Cushing’s syndrome results from excess cortisol, leading to fat redistribution, causing a round “moon face”
appearance.
A postpartum client is experiencing heavy vaginal bleeding. What is the nurse’s priority action?
A) Massage the fundus
B) Offer fluids
C) Place the client in a supine position
D) Administer a sedative
Answer: A) Massage the fundus
Explanation: Uterine atony is a common cause of postpartum hemorrhage, and fundal massage helps the uterus contract and reduce
bleeding.
Which action by the nurse can help prevent aspiration in a client with dysphagia?
