1. A nurse is preparing to administer a medication to a client. The
nurse is unsure whether the medication should be given orally or
intravenously. What is the nurse's first action?
a) Administer the medication orally.
b) Administer the medication intravenously.
c) Ask a colleague for assistance.
d) Consult the medication administration record (MAR).
Answer: d) Consult the medication administration record (MAR).
Rationale: The MAR provides accurate information on the medication,
including the route of administration. Before giving any medication, the
nurse should check the MAR to ensure they follow the correct
administration route.
2. A nurse is caring for a client who is 2 hours postoperative following
a total knee arthroplasty. The nurse notes that the client's blood
pressure is 90/60 mm Hg. Which of the following interventions should
the nurse implement first?
a) Increase the rate of the IV fluids.
b) Administer a prescribed analgesic.
c) Contact the surgeon.
d) Perform a focused assessment of the client's vital signs.
Answer: a) Increase the rate of the IV fluids.
Rationale: A blood pressure of 90/60 mm Hg can indicate hypovolemia
or dehydration, which may occur postoperatively. The nurse should first
address possible fluid volume deficit by increasing IV fluids, as this is the
most immediate intervention to help stabilize the blood pressure.
,3. A nurse is assessing a client who is 3 days postpartum following a
cesarean birth. The nurse notices that the client's lochia is bright red
and has a moderate amount of discharge. What action should the
nurse take?
a) Increase the frequency of fundal checks.
b) Reassess the client after 2 hours.
c) Document the finding as normal.
d) Notify the healthcare provider immediately.
Answer: c) Document the finding as normal.
Rationale: Lochia (postpartum vaginal discharge) initially is bright red
and moderate in amount, which is a normal finding for the first few
days postpartum. The nurse should document this and continue routine
assessments unless other abnormal signs develop.
4. A nurse is caring for a client who has a prescription for a
nonsteroidal anti-inflammatory drug (NSAID). Which of the following
actions should the nurse take to prevent an adverse effect of the
medication?
a) Administer the medication on an empty stomach.
b) Monitor the client's blood pressure.
c) Advise the client to increase fluid intake.
d) Monitor the client's urine output.
Answer: c) Advise the client to increase fluid intake.
Rationale: NSAIDs can cause kidney damage and dehydration, leading
to renal issues. To prevent these complications, the nurse should
encourage adequate fluid intake to promote renal function and prevent
dehydration.
, 5. A nurse is teaching a client about the use of an inhaler. Which of the
following actions by the client indicates that further teaching is
needed?
a) The client inhales deeply before using the inhaler.
b) The client shakes the inhaler before use.
c) The client holds their breath after inhaling the medication.
d) The client exhales forcefully before using the inhaler.
Answer: a) The client inhales deeply before using the inhaler.
Rationale: The correct technique for using an inhaler is to exhale
completely before inhaling the medication to ensure the airways are
open and the medication is effectively delivered. The client should
inhale slowly and deeply after activating the inhaler.
6. A nurse is providing discharge instructions to a client who has a new
prescription for warfarin. Which of the following client statements
indicates the need for further teaching?
a) "I will avoid foods that are high in vitamin K."
b) "I will take this medication with food to prevent stomach upset."
c) "I will notify my doctor if I notice any unusual bruising."
d) "I will take the medication at the same time each day."
Answer: b) "I will take this medication with food to prevent stomach
upset."
Rationale: Warfarin should be taken consistently at the same time each
day, but food does not directly affect the absorption of warfarin. Taking
it with food is not a requirement unless directed by the provider for
comfort. However, patients should avoid large amounts of vitamin K-
rich foods as it can interfere with the effectiveness of warfarin.
nurse is unsure whether the medication should be given orally or
intravenously. What is the nurse's first action?
a) Administer the medication orally.
b) Administer the medication intravenously.
c) Ask a colleague for assistance.
d) Consult the medication administration record (MAR).
Answer: d) Consult the medication administration record (MAR).
Rationale: The MAR provides accurate information on the medication,
including the route of administration. Before giving any medication, the
nurse should check the MAR to ensure they follow the correct
administration route.
2. A nurse is caring for a client who is 2 hours postoperative following
a total knee arthroplasty. The nurse notes that the client's blood
pressure is 90/60 mm Hg. Which of the following interventions should
the nurse implement first?
a) Increase the rate of the IV fluids.
b) Administer a prescribed analgesic.
c) Contact the surgeon.
d) Perform a focused assessment of the client's vital signs.
Answer: a) Increase the rate of the IV fluids.
Rationale: A blood pressure of 90/60 mm Hg can indicate hypovolemia
or dehydration, which may occur postoperatively. The nurse should first
address possible fluid volume deficit by increasing IV fluids, as this is the
most immediate intervention to help stabilize the blood pressure.
,3. A nurse is assessing a client who is 3 days postpartum following a
cesarean birth. The nurse notices that the client's lochia is bright red
and has a moderate amount of discharge. What action should the
nurse take?
a) Increase the frequency of fundal checks.
b) Reassess the client after 2 hours.
c) Document the finding as normal.
d) Notify the healthcare provider immediately.
Answer: c) Document the finding as normal.
Rationale: Lochia (postpartum vaginal discharge) initially is bright red
and moderate in amount, which is a normal finding for the first few
days postpartum. The nurse should document this and continue routine
assessments unless other abnormal signs develop.
4. A nurse is caring for a client who has a prescription for a
nonsteroidal anti-inflammatory drug (NSAID). Which of the following
actions should the nurse take to prevent an adverse effect of the
medication?
a) Administer the medication on an empty stomach.
b) Monitor the client's blood pressure.
c) Advise the client to increase fluid intake.
d) Monitor the client's urine output.
Answer: c) Advise the client to increase fluid intake.
Rationale: NSAIDs can cause kidney damage and dehydration, leading
to renal issues. To prevent these complications, the nurse should
encourage adequate fluid intake to promote renal function and prevent
dehydration.
, 5. A nurse is teaching a client about the use of an inhaler. Which of the
following actions by the client indicates that further teaching is
needed?
a) The client inhales deeply before using the inhaler.
b) The client shakes the inhaler before use.
c) The client holds their breath after inhaling the medication.
d) The client exhales forcefully before using the inhaler.
Answer: a) The client inhales deeply before using the inhaler.
Rationale: The correct technique for using an inhaler is to exhale
completely before inhaling the medication to ensure the airways are
open and the medication is effectively delivered. The client should
inhale slowly and deeply after activating the inhaler.
6. A nurse is providing discharge instructions to a client who has a new
prescription for warfarin. Which of the following client statements
indicates the need for further teaching?
a) "I will avoid foods that are high in vitamin K."
b) "I will take this medication with food to prevent stomach upset."
c) "I will notify my doctor if I notice any unusual bruising."
d) "I will take the medication at the same time each day."
Answer: b) "I will take this medication with food to prevent stomach
upset."
Rationale: Warfarin should be taken consistently at the same time each
day, but food does not directly affect the absorption of warfarin. Taking
it with food is not a requirement unless directed by the provider for
comfort. However, patients should avoid large amounts of vitamin K-
rich foods as it can interfere with the effectiveness of warfarin.
