All sub topics Fully Covered/ A+ GRADE Verified 100%
1.
A nurse is caring for a client admitted with acute decompensated heart failure. The client
reports worsening dyspnea, orthopnea, and has crackles auscultated bilaterally. Oxygen
saturation is 87% on room air. Which action should the nurse take first?
A. Administer IV furosemide
B. Apply supplemental oxygen
C. Obtain daily weight
D. Restrict fluid intake
Correct Answer: B
Rationale:
The client is demonstrating impaired gas exchange, which is the most immediate, life-
threatening problem. Applying supplemental oxygen directly addresses hypoxemia and
supports tissue oxygenation. While diuretics, fluid restriction, and daily weights are essential
in managing heart failure, they do not correct the immediate oxygen deficit.
2.
A nurse is educating a client newly diagnosed with type 2 diabetes mellitus about long-term
disease management. Which statement indicates correct understanding?
A. “Once my glucose improves, I won’t need to monitor it.”
B. “I should rotate finger-stick sites regularly.”
C. “Symptoms will always tell me when my sugar is low.”
D. “Oral medications eliminate the need for lifestyle changes.”
Correct Answer: B
Rationale:
Rotating finger-stick sites prevents tissue injury, reduces pain, and maintains skin integrity,
which is essential for long-term glucose monitoring. Diabetes management requires
consistent self-monitoring even when glucose levels improve. Proper technique helps ensure
accurate readings and prevents complications such as infection or callus formation.
,3.
A nurse is assessing a client with chronic kidney disease who is prescribed a low-potassium
diet. Which food choice indicates the client understands dietary restrictions?
A. Orange juice
B. Baked potato
C. White rice
D. Spinach
Correct Answer: C
Rationale:
White rice is low in potassium and appropriate for clients with impaired renal excretion of
electrolytes. Maintaining potassium within a safe range is critical to preventing life-
threatening cardiac dysrhythmias in chronic kidney disease. Proper dietary choices play a
central role in slowing disease progression and preventing complications.
4.
A postoperative client receiving IV morphine reports feeling very sleepy. Which assessment
finding requires immediate nursing intervention?
A. Pain score of 5/10
B. Respiratory rate of 8/min
C. Mild nausea
D. Decreased bowel sounds
Correct Answer: B
Rationale:
A respiratory rate of 8/min indicates opioid-induced respiratory depression, which is a
medical emergency. Opioids suppress the respiratory center in the brainstem, and early
recognition is critical to prevent hypoxia, respiratory arrest, and death. Immediate
intervention may include stopping the opioid and administering naloxone.
5.
A nurse is caring for a client suspected of having an ischemic stroke. Which diagnostic
finding supports this diagnosis?
,A. Sudden severe headache
B. CT scan showing no bleeding
C. Decreased level of consciousness
D. Projectile vomiting
Correct Answer: B
Rationale:
An ischemic stroke is characterized by an obstruction of blood flow without hemorrhage. A
CT scan that shows no evidence of bleeding confirms that the stroke is ischemic rather than
hemorrhagic, guiding treatment decisions such as thrombolytic therapy.
6.
A nurse is teaching a client with COPD techniques to prevent carbon dioxide retention.
Which intervention is most effective?
A. Deep rapid breathing
B. High-flow oxygen therapy
C. Pursed-lip breathing
D. Supine positioning
Correct Answer: C
Rationale:
Pursed-lip breathing prolongs exhalation, prevents airway collapse, and promotes more
complete removal of carbon dioxide from the lungs. COPD clients have difficulty fully
exhaling due to air trapping. This technique improves ventilation efficiency, decreases
dyspnea, and reduces the work of breathing without compromising respiratory drive.
7.
A client with liver cirrhosis develops confusion and disorientation. Which laboratory value is
most directly associated with this change?
A. Elevated bilirubin
B. Increased ammonia
C. Low albumin
D. Prolonged INR
, Correct Answer: B
Rationale:
Elevated ammonia levels occur when the damaged liver is unable to detoxify waste products.
Ammonia crosses the blood–brain barrier, leading to cerebral edema and altered mental
status known as hepatic encephalopathy. Early recognition is essential to prevent progression
to coma.
8.
A nurse is administering packed red blood cells when the client suddenly develops flank pain
and dark urine. What is the priority interpretation?
A. Febrile reaction
B. Acute hemolytic transfusion reaction
C. Allergic reaction
D. Circulatory overload
Correct Answer: B
Rationale:
Flank pain and dark urine indicate rapid destruction of red blood cells, which can lead to
acute kidney injury and shock. This reaction is caused by blood incompatibility and requires
immediate cessation of the transfusion to prevent fatal complications.
9.
A neutropenic client asks how to reduce infection risk at home. Which instruction is most
important?
A. Avoid raw fruits and vegetables
B. Exercise daily
C. Receive live vaccines
D. Discontinue handwashing when alone
Correct Answer: A
Rationale:
Raw fruits and vegetables can harbor bacteria and fungi that pose a serious infection risk to