1. A patient with chronic heart failure is prescribed digoxin. Which
assessment finding indicates a therapeutic response to the
medication?
A. Decreased blood pressure
B. Increased heart rate
C. Decreased shortness of breath
D. Increased peripheral edema
Correct Answer: C
Rationale: Digoxin is a cardiac glycoside that increases the force of
myocardial contraction, leading to improved cardiac output. A
therapeutic response is characterized by reduced signs of heart
failure, including decreased shortness of breath, reduced fatigue, and
less peripheral edema. A decreased heart rate, not increased, is
expected. Peripheral edema should decrease, not increase .
2. The nurse is caring for a client with a pulmonary embolism.
Which assessment finding requires immediate intervention?
,A. Pulse oximetry of 88%
B. Respiratory rate of 22 breaths/min
C. Blood pressure of 140/90 mmHg
D. Complaint of chest pain
Correct Answer: A
Rationale: A pulse oximetry of 88% indicates significant hypoxemia
and inadequate oxygenation, which requires immediate intervention.
A respiratory rate of 22 is slightly elevated but not immediately
critical. A blood pressure of 140/90 mmHg is elevated but not an
immediate crisis. Chest pain is expected with pulmonary embolism
and requires intervention, but hypoxemia is the priority .
3. A patient is being discharged with a new prescription for warfarin.
Which statement by the patient indicates a need for further teaching?
A. "I will avoid eating large amounts of leafy green vegetables."
B. "I will take my medication at the same time every day."
C. "I will use a soft-bristled toothbrush."
D. "I will take ibuprofen for my headaches."
Correct Answer: D
Rationale: Ibuprofen is a nonsteroidal anti-inflammatory drug
(NSAID) that increases the risk of bleeding when taken with
,warfarin. Patients should be taught to avoid NSAIDs and use
acetaminophen for pain. Consistent dosing, soft-bristled
toothbrushes, and consistent vitamin K intake (avoiding large
amounts of leafy greens) are appropriate teaching points .
4. A patient with chronic obstructive pulmonary disease (COPD) has
an arterial blood gas (ABG) with the following results: pH 7.30,
PaCO2 55 mmHg, HCO3 26 mEq/L. The nurse interprets these
results as:
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: C
Rationale: The ABG results show a decreased pH (7.30) indicating
acidosis, an elevated PaCO2 (55 mmHg) indicating respiratory
involvement, and a normal HCO3. This pattern is consistent with
respiratory acidosis, which is common in COPD patients with
carbon dioxide retention. In metabolic acidosis, HCO3 would be
decreased. In alkalosis, pH would be elevated .
5. The nurse is assessing a patient with left-sided heart failure. Which
finding is most consistent with this condition?
, A. Jugular venous distention
B. Peripheral edema
C. Crackles in the lungs
D. Hepatomegaly
Correct Answer: C
Rationale: Left-sided heart failure results in pulmonary congestion,
leading to crackles (rales) in the lungs, dyspnea, and cough. Jugular
venous distention, peripheral edema, and hepatomegaly are signs of
right-sided heart failure .
6. A patient is admitted with acute exacerbation of asthma. The
nurse should first administer:
A. Inhaled corticosteroids
B. Inhaled bronchodilators
C. Oral antibiotics
D. Intravenous fluids
Correct Answer: B
Rationale: In an acute asthma exacerbation, the priority intervention
is to relieve bronchospasm with fast-acting inhaled bronchodilators
(e.g., albuterol). Inhaled corticosteroids are used for long-term
assessment finding indicates a therapeutic response to the
medication?
A. Decreased blood pressure
B. Increased heart rate
C. Decreased shortness of breath
D. Increased peripheral edema
Correct Answer: C
Rationale: Digoxin is a cardiac glycoside that increases the force of
myocardial contraction, leading to improved cardiac output. A
therapeutic response is characterized by reduced signs of heart
failure, including decreased shortness of breath, reduced fatigue, and
less peripheral edema. A decreased heart rate, not increased, is
expected. Peripheral edema should decrease, not increase .
2. The nurse is caring for a client with a pulmonary embolism.
Which assessment finding requires immediate intervention?
,A. Pulse oximetry of 88%
B. Respiratory rate of 22 breaths/min
C. Blood pressure of 140/90 mmHg
D. Complaint of chest pain
Correct Answer: A
Rationale: A pulse oximetry of 88% indicates significant hypoxemia
and inadequate oxygenation, which requires immediate intervention.
A respiratory rate of 22 is slightly elevated but not immediately
critical. A blood pressure of 140/90 mmHg is elevated but not an
immediate crisis. Chest pain is expected with pulmonary embolism
and requires intervention, but hypoxemia is the priority .
3. A patient is being discharged with a new prescription for warfarin.
Which statement by the patient indicates a need for further teaching?
A. "I will avoid eating large amounts of leafy green vegetables."
B. "I will take my medication at the same time every day."
C. "I will use a soft-bristled toothbrush."
D. "I will take ibuprofen for my headaches."
Correct Answer: D
Rationale: Ibuprofen is a nonsteroidal anti-inflammatory drug
(NSAID) that increases the risk of bleeding when taken with
,warfarin. Patients should be taught to avoid NSAIDs and use
acetaminophen for pain. Consistent dosing, soft-bristled
toothbrushes, and consistent vitamin K intake (avoiding large
amounts of leafy greens) are appropriate teaching points .
4. A patient with chronic obstructive pulmonary disease (COPD) has
an arterial blood gas (ABG) with the following results: pH 7.30,
PaCO2 55 mmHg, HCO3 26 mEq/L. The nurse interprets these
results as:
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: C
Rationale: The ABG results show a decreased pH (7.30) indicating
acidosis, an elevated PaCO2 (55 mmHg) indicating respiratory
involvement, and a normal HCO3. This pattern is consistent with
respiratory acidosis, which is common in COPD patients with
carbon dioxide retention. In metabolic acidosis, HCO3 would be
decreased. In alkalosis, pH would be elevated .
5. The nurse is assessing a patient with left-sided heart failure. Which
finding is most consistent with this condition?
, A. Jugular venous distention
B. Peripheral edema
C. Crackles in the lungs
D. Hepatomegaly
Correct Answer: C
Rationale: Left-sided heart failure results in pulmonary congestion,
leading to crackles (rales) in the lungs, dyspnea, and cough. Jugular
venous distention, peripheral edema, and hepatomegaly are signs of
right-sided heart failure .
6. A patient is admitted with acute exacerbation of asthma. The
nurse should first administer:
A. Inhaled corticosteroids
B. Inhaled bronchodilators
C. Oral antibiotics
D. Intravenous fluids
Correct Answer: B
Rationale: In an acute asthma exacerbation, the priority intervention
is to relieve bronchospasm with fast-acting inhaled bronchodilators
(e.g., albuterol). Inhaled corticosteroids are used for long-term
