1. A nurse is teaching a client with a new diagnosis of hypertension
about lifestyle modifications. Which of the following statements by the
client indicates understanding? a) "I will increase my intake of salt to
help regulate my blood pressure." b) "I will exercise for at least 30
minutes most days of the week." c) "I will stop drinking water and only
drink caffeinated beverages." d) "I will avoid eating foods high in fiber
to keep my blood pressure normal."
Answer: b) "I will exercise for at least 30 minutes most days of the
week."
Rationale: Regular exercise is an important lifestyle modification for
managing hypertension. It can help lower blood pressure and improve
overall cardiovascular health.
2. A nurse is caring for a client with a diagnosis of congestive heart
failure (CHF). Which of the following findings should the nurse report
to the healthcare provider immediately? a) Blood pressure of 120/80
mmHg b) Increased shortness of breath on exertion c) Weight gain of 2
pounds over the past 24 hours d) Heart rate of 90 bpm
Answer: c) Weight gain of 2 pounds over the past 24 hours
Rationale: Rapid weight gain, particularly more than 2 pounds per day,
is a sign of fluid retention and could indicate worsening heart failure.
Immediate reporting is necessary for appropriate intervention.
,3. A nurse is caring for a client with chronic heart failure. Which of the
following actions should the nurse take first to assess the client's
condition? a) Monitor the client's weight b) Auscultate the lungs for
crackles c) Check the client's blood pressure d) Assess the client's
peripheral pulses
Answer: b) Auscultate the lungs for crackles
Rationale: Crackles are a common sign of fluid overload in heart failure.
Auscultating the lungs should be done first to assess for pulmonary
congestion.
4. A nurse is caring for a client who has a prescription for a chest X-
ray. Which of the following is the most important question the nurse
should ask the client before the procedure? a) "Do you have a history of
asthma?" b) "Are you allergic to shellfish?" c) "Are you pregnant or is
there a chance you could be pregnant?" d) "Have you ever had a blood
transfusion?"
Answer: c) "Are you pregnant or is there a chance you could be
pregnant?"
Rationale: X-rays involve radiation, which can be harmful to a
developing fetus. It is essential to determine if the client is pregnant
before proceeding with the procedure.
5. A nurse is caring for a client with diabetes mellitus who has
developed diabetic ketoacidosis (DKA). Which of the following
interventions is most important? a) Administer intravenous insulin as
prescribed b) Encourage the client to drink fluids c) Monitor the
client's blood pressure d) Administer oral hypoglycemic agents
, Answer: a) Administer intravenous insulin as prescribed
Rationale: IV insulin is the primary treatment for diabetic ketoacidosis
(DKA). It helps lower blood glucose levels and correct the metabolic
acidosis associated with DKA.
6. A nurse is caring for a client who is receiving intravenous (IV)
antibiotics. Which of the following actions is most important to prevent
the risk of thrombophlebitis? a) Administer the antibiotic slowly over
the recommended time b) Flush the IV line with normal saline after
each dose c) Keep the IV site covered with a sterile dressing at all times
d) Rotate the IV site every 48 hours
Answer: a) Administer the antibiotic slowly over the recommended
time
Rationale: Administering the antibiotic slowly reduces the risk of
irritation to the vein, which can lead to thrombophlebitis. The nurse
should also monitor the IV site regularly.
7. A nurse is caring for a client with a fractured femur. Which of the
following interventions is most important to include in the plan of
care? a) Encourage the client to ambulate as soon as possible b) Assess
the client's neurovascular status frequently c) Apply a cold compress to
the fractured site d) Provide the client with a high-calorie diet
Answer: b) Assess the client's neurovascular status frequently
Rationale: Assessing neurovascular status is essential to monitor for
complications like compartment syndrome, which can result from a
fracture. This assessment helps ensure proper blood flow and nerve
function.
about lifestyle modifications. Which of the following statements by the
client indicates understanding? a) "I will increase my intake of salt to
help regulate my blood pressure." b) "I will exercise for at least 30
minutes most days of the week." c) "I will stop drinking water and only
drink caffeinated beverages." d) "I will avoid eating foods high in fiber
to keep my blood pressure normal."
Answer: b) "I will exercise for at least 30 minutes most days of the
week."
Rationale: Regular exercise is an important lifestyle modification for
managing hypertension. It can help lower blood pressure and improve
overall cardiovascular health.
2. A nurse is caring for a client with a diagnosis of congestive heart
failure (CHF). Which of the following findings should the nurse report
to the healthcare provider immediately? a) Blood pressure of 120/80
mmHg b) Increased shortness of breath on exertion c) Weight gain of 2
pounds over the past 24 hours d) Heart rate of 90 bpm
Answer: c) Weight gain of 2 pounds over the past 24 hours
Rationale: Rapid weight gain, particularly more than 2 pounds per day,
is a sign of fluid retention and could indicate worsening heart failure.
Immediate reporting is necessary for appropriate intervention.
,3. A nurse is caring for a client with chronic heart failure. Which of the
following actions should the nurse take first to assess the client's
condition? a) Monitor the client's weight b) Auscultate the lungs for
crackles c) Check the client's blood pressure d) Assess the client's
peripheral pulses
Answer: b) Auscultate the lungs for crackles
Rationale: Crackles are a common sign of fluid overload in heart failure.
Auscultating the lungs should be done first to assess for pulmonary
congestion.
4. A nurse is caring for a client who has a prescription for a chest X-
ray. Which of the following is the most important question the nurse
should ask the client before the procedure? a) "Do you have a history of
asthma?" b) "Are you allergic to shellfish?" c) "Are you pregnant or is
there a chance you could be pregnant?" d) "Have you ever had a blood
transfusion?"
Answer: c) "Are you pregnant or is there a chance you could be
pregnant?"
Rationale: X-rays involve radiation, which can be harmful to a
developing fetus. It is essential to determine if the client is pregnant
before proceeding with the procedure.
5. A nurse is caring for a client with diabetes mellitus who has
developed diabetic ketoacidosis (DKA). Which of the following
interventions is most important? a) Administer intravenous insulin as
prescribed b) Encourage the client to drink fluids c) Monitor the
client's blood pressure d) Administer oral hypoglycemic agents
, Answer: a) Administer intravenous insulin as prescribed
Rationale: IV insulin is the primary treatment for diabetic ketoacidosis
(DKA). It helps lower blood glucose levels and correct the metabolic
acidosis associated with DKA.
6. A nurse is caring for a client who is receiving intravenous (IV)
antibiotics. Which of the following actions is most important to prevent
the risk of thrombophlebitis? a) Administer the antibiotic slowly over
the recommended time b) Flush the IV line with normal saline after
each dose c) Keep the IV site covered with a sterile dressing at all times
d) Rotate the IV site every 48 hours
Answer: a) Administer the antibiotic slowly over the recommended
time
Rationale: Administering the antibiotic slowly reduces the risk of
irritation to the vein, which can lead to thrombophlebitis. The nurse
should also monitor the IV site regularly.
7. A nurse is caring for a client with a fractured femur. Which of the
following interventions is most important to include in the plan of
care? a) Encourage the client to ambulate as soon as possible b) Assess
the client's neurovascular status frequently c) Apply a cold compress to
the fractured site d) Provide the client with a high-calorie diet
Answer: b) Assess the client's neurovascular status frequently
Rationale: Assessing neurovascular status is essential to monitor for
complications like compartment syndrome, which can result from a
fracture. This assessment helps ensure proper blood flow and nerve
function.
