1. 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.
2. A nurse is teaching a client with asthma about the proper use of a
metered-dose inhaler (MDI). Which of the following actions indicates
that the client understands the instructions? a) "I will hold my breath
for 5 seconds after inhaling the medication." b) "I will exhale deeply
before inhaling the medication." c) "I will shake the inhaler for 10
seconds before each use." d) "I will inhale the medication with a fast
and deep breath."
Answer: c) "I will shake the inhaler for 10 seconds before each use."
Rationale: Shaking the inhaler before use ensures the medication is
properly mixed. It is also essential to exhale before inhaling, but the
key is ensuring proper technique.
3. A nurse is caring for a client with an acute asthma attack. Which of
the following medications should the nurse administer first? a)
,Intravenous corticosteroids b) Oral antibiotics c) Short-acting beta-
agonist (SABA) inhaler d) Long-acting beta-agonist (LABA) inhaler
Answer: c) Short-acting beta-agonist (SABA) inhaler
Rationale: A SABA, such as albuterol, is the first-line treatment for
acute asthma attacks. It helps to quickly open the airways and relieve
symptoms.
4. 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.
5. A nurse is preparing to administer a prescribed dose of insulin to a
client with type 1 diabetes. Which of the following actions should the
nurse take before administering the insulin? a) Check the client's blood
glucose level b) Have the client eat a snack c) Cleanse the injection site
with alcohol d) Draw up insulin into the syringe and administer
immediately
Answer: a) Check the client's blood glucose level
, Rationale: Checking the client's blood glucose level ensures that the
insulin dose is appropriate based on their current blood sugar. It is
important to avoid administering insulin without this step.
6. Which of the following would be a priority for a nurse when caring
for a client who is admitted with chest pain and suspected myocardial
infarction (MI)? a) Obtain a complete health history b) Prepare the
client for a stress test c) Administer oxygen and administer
nitroglycerin as prescribed d) Begin an IV infusion of normal saline
Answer: c) Administer oxygen and administer nitroglycerin as
prescribed
Rationale: Oxygen and nitroglycerin are administered to relieve chest
pain and improve oxygenation in the event of a suspected MI. This is a
priority over other actions.
7. 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.
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.
2. A nurse is teaching a client with asthma about the proper use of a
metered-dose inhaler (MDI). Which of the following actions indicates
that the client understands the instructions? a) "I will hold my breath
for 5 seconds after inhaling the medication." b) "I will exhale deeply
before inhaling the medication." c) "I will shake the inhaler for 10
seconds before each use." d) "I will inhale the medication with a fast
and deep breath."
Answer: c) "I will shake the inhaler for 10 seconds before each use."
Rationale: Shaking the inhaler before use ensures the medication is
properly mixed. It is also essential to exhale before inhaling, but the
key is ensuring proper technique.
3. A nurse is caring for a client with an acute asthma attack. Which of
the following medications should the nurse administer first? a)
,Intravenous corticosteroids b) Oral antibiotics c) Short-acting beta-
agonist (SABA) inhaler d) Long-acting beta-agonist (LABA) inhaler
Answer: c) Short-acting beta-agonist (SABA) inhaler
Rationale: A SABA, such as albuterol, is the first-line treatment for
acute asthma attacks. It helps to quickly open the airways and relieve
symptoms.
4. 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.
5. A nurse is preparing to administer a prescribed dose of insulin to a
client with type 1 diabetes. Which of the following actions should the
nurse take before administering the insulin? a) Check the client's blood
glucose level b) Have the client eat a snack c) Cleanse the injection site
with alcohol d) Draw up insulin into the syringe and administer
immediately
Answer: a) Check the client's blood glucose level
, Rationale: Checking the client's blood glucose level ensures that the
insulin dose is appropriate based on their current blood sugar. It is
important to avoid administering insulin without this step.
6. Which of the following would be a priority for a nurse when caring
for a client who is admitted with chest pain and suspected myocardial
infarction (MI)? a) Obtain a complete health history b) Prepare the
client for a stress test c) Administer oxygen and administer
nitroglycerin as prescribed d) Begin an IV infusion of normal saline
Answer: c) Administer oxygen and administer nitroglycerin as
prescribed
Rationale: Oxygen and nitroglycerin are administered to relieve chest
pain and improve oxygenation in the event of a suspected MI. This is a
priority over other actions.
7. 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.
