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A client with heart failure is prescribed furosemide. Which finding requires immediate
intervention?
A. Potassium 3.1 mEq/L
B. Blood pressure 130/80 mmHg
C. Urine output 800 mL in 8 hours
D. Weight loss of 1 lb in 24 hours
Answer: A
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. A potassium level
of 3.1 mEq/L is critically low and increases the risk of life-threatening dysrhythmias.
A nurse is assessing a client with pneumonia. Which finding is most concerning?
A. Respiratory rate 22/min
B. Oxygen saturation 91%
C. Productive cough
D. Mild chest discomfort
Answer: B
Rationale: Oxygen saturation of 91% indicates hypoxemia and requires prompt
intervention.
A postoperative client suddenly develops shortness of breath and chest pain. What is
the nurse’s priority action?
A. Administer pain medication
B. Encourage deep breathing
,C. Assess oxygen saturation
D. Call the provider
Answer: C
Rationale: The nurse must first assess oxygenation to determine severity and guide
immediate intervention.
A client with diabetes has a blood glucose of 58 mg/dL. What is the nurse’s first action?
A. Administer insulin
B. Give 15 g of fast-acting carbohydrates
C. Recheck in 2 hours
D. Notify the provider
Answer: B
Rationale: The client is hypoglycemic and requires immediate glucose replacement.
Which laboratory value should the nurse report immediately?
A. Sodium 140 mEq/L
B. Potassium 5.8 mEq/L
C. Calcium 9.0 mg/dL
D. Hemoglobin 13 g/dL
Answer: B
Rationale: Hyperkalemia can cause fatal cardiac dysrhythmias.
A client is receiving morphine. Which sign indicates respiratory depression?
A. RR 18/min
B. RR 10/min
C. BP 120/80 mmHg
D. HR 88 bpm
Answer: B
, Rationale: A respiratory rate below 12/min indicates opioid-induced respiratory
depression.
A nurse is caring for a client with a chest tube. What indicates a complication?
A. Tidaling in water seal chamber
B. Continuous bubbling in suction chamber
C. Absence of drainage
D. Serosanguinous drainage
Answer: C
Rationale: Absence of drainage may indicate obstruction or lung re-expansion.
Which client should the nurse assess first?
A. Client with asthma reporting mild wheezing
B. Client with CHF and crackles
C. Client with COPD and SpO2 88%
D. Client awaiting discharge
Answer: C
Rationale: Low oxygen saturation indicates respiratory compromise.
A nurse is teaching about insulin administration. Which statement indicates
understanding?
A. “I will inject into the same site each time.”
B. “I will rotate injection sites.”
C. “I will skip insulin when sick.”
D. “I will mix all insulins together.”
Answer: B
Rationale: Rotating sites prevents lipodystrophy.
A client has signs of stroke. What is the priority action?