1. A nurse is caring for a client with a diagnosis of pneumonia. Which
of the following is the priority intervention for this client?
A) Administer prescribed antibiotics
B) Encourage fluid intake
C) Administer oxygen therapy as ordered
D) Provide a high-calorie, high-protein diet
Answer: C) Administer oxygen therapy as ordered
Rationale: Oxygen therapy is the priority for clients with pneumonia
because it ensures adequate oxygenation and prevents respiratory
failure. While antibiotics (A) are essential for treating the infection,
maintaining oxygenation is the immediate priority. Encouraging fluid
intake (B) and providing a high-calorie diet (D) are important but not
immediate priorities.
2. A nurse is caring for a client post-surgery who is receiving opioids
for pain management. Which of the following is the priority
assessment when administering opioids?
A) Blood pressure
B) Respiratory rate
C) Temperature
D) Heart rate
Answer: B) Respiratory rate
Rationale: Opioids can depress the respiratory system, so monitoring
the respiratory rate is the priority to ensure the client is not
experiencing respiratory depression. While blood pressure (A),
temperature (C), and heart rate (D) are important, they are secondary
to assessing respiratory function.
,3. A nurse is caring for a client with type 1 diabetes mellitus who is
admitted with diabetic ketoacidosis (DKA). Which of the following
laboratory results is the nurse most likely to find?
A) Low blood glucose levels
B) Low arterial pH
C) Elevated serum potassium
D) High bicarbonate levels
Answer: B) Low arterial pH
Rationale: Diabetic ketoacidosis (DKA) leads to acidosis, resulting in a
decreased pH in arterial blood. Elevated potassium (C) can occur, but
the pH imbalance is the hallmark of DKA. Blood glucose is typically
elevated in DKA, not low (A), and bicarbonate levels (D) are typically low
due to metabolic acidosis.
4. A nurse is caring for a client with heart failure. The client is
receiving furosemide. The nurse should monitor for which of the
following potential adverse effects of this medication?
A) Hyperkalemia
B) Hypokalemia
C) Hypertension
D) Hyperglycemia
Answer: B) Hypokalemia
Rationale: Furosemide is a loop diuretic that promotes the excretion of
potassium, which can lead to hypokalemia. Hypokalemia can cause
serious complications, including arrhythmias. Hyperkalemia (A) is more
, common with potassium-sparing diuretics. Hypertension (C) and
hyperglycemia (D) are not typical adverse effects of furosemide.
5. A nurse is caring for a client with a new diagnosis of hypertension.
The nurse should expect the healthcare provider to prescribe which of
the following medications as the first-line treatment?
A) Calcium channel blockers
B) Beta-blockers
C) Angiotensin-converting enzyme inhibitors
D) Diuretics
Answer: D) Diuretics
Rationale: Diuretics are often prescribed as first-line treatment for
hypertension as they reduce fluid volume and lower blood pressure.
While ACE inhibitors (C), calcium channel blockers (A), and beta-
blockers (B) may be used, diuretics are typically the initial therapy.
6. A nurse is caring for a client with cirrhosis of the liver. The nurse
should be alert for which of the following potential complications?
A) Hyperkalemia
B) Ascites
C) Hypoglycemia
D) Hypercalcemia
Answer: B) Ascites
Rationale: Ascites, the accumulation of fluid in the abdomen, is a
common complication of cirrhosis due to impaired liver function and
portal hypertension. Hyperkalemia (A) and hypoglycemia (C) are less
of the following is the priority intervention for this client?
A) Administer prescribed antibiotics
B) Encourage fluid intake
C) Administer oxygen therapy as ordered
D) Provide a high-calorie, high-protein diet
Answer: C) Administer oxygen therapy as ordered
Rationale: Oxygen therapy is the priority for clients with pneumonia
because it ensures adequate oxygenation and prevents respiratory
failure. While antibiotics (A) are essential for treating the infection,
maintaining oxygenation is the immediate priority. Encouraging fluid
intake (B) and providing a high-calorie diet (D) are important but not
immediate priorities.
2. A nurse is caring for a client post-surgery who is receiving opioids
for pain management. Which of the following is the priority
assessment when administering opioids?
A) Blood pressure
B) Respiratory rate
C) Temperature
D) Heart rate
Answer: B) Respiratory rate
Rationale: Opioids can depress the respiratory system, so monitoring
the respiratory rate is the priority to ensure the client is not
experiencing respiratory depression. While blood pressure (A),
temperature (C), and heart rate (D) are important, they are secondary
to assessing respiratory function.
,3. A nurse is caring for a client with type 1 diabetes mellitus who is
admitted with diabetic ketoacidosis (DKA). Which of the following
laboratory results is the nurse most likely to find?
A) Low blood glucose levels
B) Low arterial pH
C) Elevated serum potassium
D) High bicarbonate levels
Answer: B) Low arterial pH
Rationale: Diabetic ketoacidosis (DKA) leads to acidosis, resulting in a
decreased pH in arterial blood. Elevated potassium (C) can occur, but
the pH imbalance is the hallmark of DKA. Blood glucose is typically
elevated in DKA, not low (A), and bicarbonate levels (D) are typically low
due to metabolic acidosis.
4. A nurse is caring for a client with heart failure. The client is
receiving furosemide. The nurse should monitor for which of the
following potential adverse effects of this medication?
A) Hyperkalemia
B) Hypokalemia
C) Hypertension
D) Hyperglycemia
Answer: B) Hypokalemia
Rationale: Furosemide is a loop diuretic that promotes the excretion of
potassium, which can lead to hypokalemia. Hypokalemia can cause
serious complications, including arrhythmias. Hyperkalemia (A) is more
, common with potassium-sparing diuretics. Hypertension (C) and
hyperglycemia (D) are not typical adverse effects of furosemide.
5. A nurse is caring for a client with a new diagnosis of hypertension.
The nurse should expect the healthcare provider to prescribe which of
the following medications as the first-line treatment?
A) Calcium channel blockers
B) Beta-blockers
C) Angiotensin-converting enzyme inhibitors
D) Diuretics
Answer: D) Diuretics
Rationale: Diuretics are often prescribed as first-line treatment for
hypertension as they reduce fluid volume and lower blood pressure.
While ACE inhibitors (C), calcium channel blockers (A), and beta-
blockers (B) may be used, diuretics are typically the initial therapy.
6. A nurse is caring for a client with cirrhosis of the liver. The nurse
should be alert for which of the following potential complications?
A) Hyperkalemia
B) Ascites
C) Hypoglycemia
D) Hypercalcemia
Answer: B) Ascites
Rationale: Ascites, the accumulation of fluid in the abdomen, is a
common complication of cirrhosis due to impaired liver function and
portal hypertension. Hyperkalemia (A) and hypoglycemia (C) are less
