1. Which of the following is the most important intervention for a
nurse to implement when caring for a patient with chronic kidney
disease (CKD) to prevent complications?
A) Administer antibiotics as prescribed
B) Monitor fluid intake and output
C) Restrict potassium intake
D) Perform frequent blood glucose checks
Answer: B) Monitor fluid intake and output
Rationale: Monitoring fluid intake and output is crucial in managing
CKD, as fluid overload can lead to complications such as edema,
hypertension, and heart failure. Restricting potassium and
administering antibiotics are interventions for specific conditions, but
fluid balance is the primary concern in CKD management.
2. A nurse is assessing a patient with heart failure. Which of the
following findings is most indicative of worsening heart failure?
A) Decreased urine output
B) Weight loss
C) Decreased blood pressure
D) Increased respiratory rate
Answer: A) Decreased urine output
Rationale: Decreased urine output is an indicator of fluid retention,
which is common in worsening heart failure. This occurs because the
kidneys receive less blood flow due to decreased cardiac output. Other
findings such as weight loss or decreased blood pressure are not as
strongly indicative of worsening heart failure as decreased urine output.
,3. A nurse is caring for a patient who is post-operative following a
right-sided mastectomy. Which of the following actions should the
nurse take to prevent complications?
A) Encourage the patient to perform arm exercises on the affected side
B) Keep the right arm in a dependent position
C) Apply a pressure bandage to the surgical site
D) Elevate the right arm above the level of the heart
Answer: D) Elevate the right arm above the level of the heart
Rationale: Elevating the affected arm above the level of the heart
promotes venous return and reduces edema after a mastectomy. It is
important to avoid keeping the arm dependent, as this can lead to
increased swelling. Exercises on the affected side should be discussed
with the healthcare provider and typically started only after initial
healing.
4. Which of the following is a priority intervention for a patient with a
diagnosis of acute pancreatitis?
A) Encourage a high-fat diet
B) Administer opioid analgesics as prescribed
C) Provide a high-protein diet
D) Keep the patient NPO (nil per os)
Answer: D) Keep the patient NPO
Rationale: Keeping the patient NPO is important to rest the pancreas
and prevent stimulation of digestive enzymes, which could exacerbate
inflammation. Opioids may be needed for pain management, but they
should not be the priority intervention. A high-fat or high-protein diet
would worsen the condition.
, 5. A nurse is caring for a patient with a history of chronic obstructive
pulmonary disease (COPD). Which of the following findings indicates a
potential complication requiring immediate attention?
A) Productive cough
B) Increased respiratory rate
C) Bluish tint to lips and fingers
D) Exertional dyspnea
Answer: C) Bluish tint to lips and fingers
Rationale: A bluish tint to the lips and fingers indicates cyanosis, which
is a sign of hypoxemia and a serious complication in patients with COPD.
Immediate intervention is required to improve oxygenation. Although
other symptoms like productive cough and exertional dyspnea are
common, cyanosis is a more urgent concern.
6. Which of the following findings would the nurse expect to assess in
a patient with cirrhosis of the liver?
A) Hypoglycemia
B) Jaundice
C) Bradycardia
D) Polyuria
Answer: B) Jaundice
Rationale: Jaundice is a common finding in cirrhosis due to the liver's
impaired ability to process bilirubin. This leads to the accumulation of
bilirubin in the bloodstream. Other findings, such as hypoglycemia or
polyuria, are not typical of cirrhosis, and bradycardia is not commonly
associated.
nurse to implement when caring for a patient with chronic kidney
disease (CKD) to prevent complications?
A) Administer antibiotics as prescribed
B) Monitor fluid intake and output
C) Restrict potassium intake
D) Perform frequent blood glucose checks
Answer: B) Monitor fluid intake and output
Rationale: Monitoring fluid intake and output is crucial in managing
CKD, as fluid overload can lead to complications such as edema,
hypertension, and heart failure. Restricting potassium and
administering antibiotics are interventions for specific conditions, but
fluid balance is the primary concern in CKD management.
2. A nurse is assessing a patient with heart failure. Which of the
following findings is most indicative of worsening heart failure?
A) Decreased urine output
B) Weight loss
C) Decreased blood pressure
D) Increased respiratory rate
Answer: A) Decreased urine output
Rationale: Decreased urine output is an indicator of fluid retention,
which is common in worsening heart failure. This occurs because the
kidneys receive less blood flow due to decreased cardiac output. Other
findings such as weight loss or decreased blood pressure are not as
strongly indicative of worsening heart failure as decreased urine output.
,3. A nurse is caring for a patient who is post-operative following a
right-sided mastectomy. Which of the following actions should the
nurse take to prevent complications?
A) Encourage the patient to perform arm exercises on the affected side
B) Keep the right arm in a dependent position
C) Apply a pressure bandage to the surgical site
D) Elevate the right arm above the level of the heart
Answer: D) Elevate the right arm above the level of the heart
Rationale: Elevating the affected arm above the level of the heart
promotes venous return and reduces edema after a mastectomy. It is
important to avoid keeping the arm dependent, as this can lead to
increased swelling. Exercises on the affected side should be discussed
with the healthcare provider and typically started only after initial
healing.
4. Which of the following is a priority intervention for a patient with a
diagnosis of acute pancreatitis?
A) Encourage a high-fat diet
B) Administer opioid analgesics as prescribed
C) Provide a high-protein diet
D) Keep the patient NPO (nil per os)
Answer: D) Keep the patient NPO
Rationale: Keeping the patient NPO is important to rest the pancreas
and prevent stimulation of digestive enzymes, which could exacerbate
inflammation. Opioids may be needed for pain management, but they
should not be the priority intervention. A high-fat or high-protein diet
would worsen the condition.
, 5. A nurse is caring for a patient with a history of chronic obstructive
pulmonary disease (COPD). Which of the following findings indicates a
potential complication requiring immediate attention?
A) Productive cough
B) Increased respiratory rate
C) Bluish tint to lips and fingers
D) Exertional dyspnea
Answer: C) Bluish tint to lips and fingers
Rationale: A bluish tint to the lips and fingers indicates cyanosis, which
is a sign of hypoxemia and a serious complication in patients with COPD.
Immediate intervention is required to improve oxygenation. Although
other symptoms like productive cough and exertional dyspnea are
common, cyanosis is a more urgent concern.
6. Which of the following findings would the nurse expect to assess in
a patient with cirrhosis of the liver?
A) Hypoglycemia
B) Jaundice
C) Bradycardia
D) Polyuria
Answer: B) Jaundice
Rationale: Jaundice is a common finding in cirrhosis due to the liver's
impaired ability to process bilirubin. This leads to the accumulation of
bilirubin in the bloodstream. Other findings, such as hypoglycemia or
polyuria, are not typical of cirrhosis, and bradycardia is not commonly
associated.
