Questions and Answers | Latest
Version | 2025/2026 | Correct & Verified
A nurse enters a room and finds a client lying on the floor. What is the nurse’s first action?
a. Ask what happened
✔✔b. Assess the client for injury
c. Notify the provider
d. Document the incident
**Rationale:** Safety and assessment come first after a fall.
A client with heart failure reports increased shortness of breath and swelling in legs. What should
the nurse do first?
✔✔a. Assess lung sounds and oxygen saturation
b. Notify the healthcare provider
c. Reposition the client in bed
d. Measure daily weight
**Rationale:** Assessment directs immediate care in worsening heart failure.
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,A nurse is teaching a client how to use a metered-dose inhaler. Which action by the client
indicates understanding?
a. Exhales immediately after inhaling
✔✔b. Holds breath for 10 seconds after inhalation
c. Uses inhaler while lying down
d. Shakes inhaler after each puff
**Rationale:** Holding breath allows medication absorption.
A nurse finds a client’s urinary catheter disconnected from the drainage bag. What should the
nurse do first?
✔✔a. Replace with a new sterile catheter connection
b. Reconnect the tubing immediately
c. Flush the catheter with saline
d. Call the provider
**Rationale:** Maintaining sterility prevents infection.
A nurse prepares to administer oral medication. Which step ensures safe administration?
a. Crush all tablets together
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,✔✔b. Verify the client’s identity with two identifiers
c. Ask a family member to confirm the client’s name
d. Administer without gloves
**Rationale:** Verification prevents medication errors.
A client complains of itching after receiving an antibiotic. What is the nurse’s first action?
✔✔a. Assess for rash or difficulty breathing
b. Stop the medication
c. Administer antihistamine
d. Notify provider
**Rationale:** Assessment confirms severity of allergic reaction.
A client’s oxygen saturation is 84% on room air. What should the nurse do next?
a. Encourage deep breathing
✔✔b. Apply oxygen and assess airway
c. Document findings
d. Notify family
**Rationale:** Low oxygen requires immediate intervention.
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, A nurse is providing discharge teaching about warfarin. Which statement indicates correct
understanding?
✔✔a. “I’ll avoid eating large amounts of green leafy vegetables.”
b. “I’ll take double doses if I miss one.”
c. “I can stop the medication once I feel better.”
d. “I don’t need regular blood tests.”
**Rationale:** Vitamin K affects warfarin effectiveness.
A client scheduled for surgery states, “I don’t understand what the surgeon said.” What should
the nurse do?
✔✔a. Notify the surgeon to clarify information
b. Explain the procedure again
c. Have the client sign the consent form
d. Reassure that it’s routine
**Rationale:** Only the provider can obtain informed consent.
A client reports feeling faint while ambulating. What should the nurse do first?
a. Encourage the client to take deep breaths
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