1. Question:
A nurse is caring for a client who has chronic obstructive pulmonary
disease (COPD) and is experiencing increased shortness of breath. The
nurse notes that the client's oxygen saturation is 88%. What is the first
priority for the nurse to address?
• A) Administer oxygen therapy as prescribed
• B) Call the healthcare provider
• C) Increase the IV fluid rate
• D) Provide reassurance to the client
Answer: A) Administer oxygen therapy as prescribed.
Rationale:
Oxygen therapy should be administered first because the primary issue
is the low oxygen saturation (88%), which is critical for the client with
COPD. Administering oxygen will help to increase the oxygen saturation
and relieve the client's symptoms. Calling the provider or increasing the
IV fluid rate can be done after the client's respiratory status is stabilized.
Providing reassurance, while helpful, does not address the immediate
need for oxygen.
2. Question:
A nurse is teaching a client with diabetes about insulin administration.
Which of the following instructions should the nurse include?
• A) "Inject insulin into the same site for each injection."
• B) "Roll the insulin vial between your hands to warm it."
• C) "Inject the insulin into the fatty tissue just under the skin."
, • D) "You should draw up insulin and administer it immediately."
Answer: C) "Inject the insulin into the fatty tissue just under the skin."
Rationale:
Insulin should be injected into the subcutaneous (fatty) tissue, not into
muscle or vein. This allows for proper absorption. Rotating injection
sites is recommended to prevent tissue damage. Insulin should not be
rolled in the hands but rather gently swirled to avoid destroying the
insulin. It is important to draw up insulin and administer it in a timely
manner, but not necessarily immediately after drawing it.
3. Question:
A nurse is caring for a client who has just undergone surgery. The client
is at risk for postoperative pneumonia. Which of the following
interventions is most important to prevent pneumonia?
• A) Administer antibiotics as prescribed
• B) Encourage deep breathing and coughing exercises
• C) Increase the client’s fluid intake
• D) Place the client in a side-lying position
Answer: B) Encourage deep breathing and coughing exercises.
Rationale:
Deep breathing and coughing exercises help to expand the lungs, clear
secretions, and improve ventilation, which are essential in preventing
postoperative pneumonia. While antibiotics may be necessary if an
infection is present, the primary intervention to prevent pneumonia is
to maintain lung function through these exercises. Increasing fluid
,intake and positioning may help, but they are secondary to the need for
lung expansion.
4. Question:
A nurse is assessing a client who is receiving a blood transfusion. The
client suddenly experiences chills, back pain, and a fever. What is the
nurse’s first action?
• A) Stop the blood transfusion immediately
• B) Administer acetaminophen for fever
• C) Increase the IV fluid rate
• D) Notify the healthcare provider
Answer: A) Stop the blood transfusion immediately.
Rationale:
The symptoms described suggest a transfusion reaction, which can be
life-threatening. The nurse's first action is to stop the transfusion
immediately to prevent further complications. After stopping the
transfusion, the nurse should notify the healthcare provider and
provide supportive care as needed, including IV fluids and medications
to manage symptoms.
5. Question:
A nurse is caring for a client with hypertension who is prescribed a
diuretic. What is the most important assessment to monitor during
diuretic therapy?
• A) Blood pressure
, • B) Heart rate
• C) Respiratory rate
• D) Serum potassium levels
Answer: D) Serum potassium levels.
Rationale:
Diuretics can cause a loss of potassium, leading to hypokalemia, which
can cause serious cardiac and muscular issues. The nurse should closely
monitor the client's potassium levels, especially with diuretics like
furosemide. While blood pressure and heart rate are important to
monitor in hypertensive clients, potassium levels are the most critical
for this medication.
6. Question:
A nurse is caring for a client with a fractured femur. The client is in a
cast and reports increasing pain despite receiving prescribed pain
medications. What is the nurse’s first action?
• A) Assess the cast for tightness or pressure
• B) Increase the client’s pain medication dosage
• C) Reassure the client that pain is normal
• D) Encourage the client to perform deep breathing exercises
Answer: A) Assess the cast for tightness or pressure.
Rationale:
Increasing pain in a client with a cast could indicate complications such
as compartment syndrome, which requires immediate intervention. The
nurse should first assess the cast for tightness or signs of pressure,
A nurse is caring for a client who has chronic obstructive pulmonary
disease (COPD) and is experiencing increased shortness of breath. The
nurse notes that the client's oxygen saturation is 88%. What is the first
priority for the nurse to address?
• A) Administer oxygen therapy as prescribed
• B) Call the healthcare provider
• C) Increase the IV fluid rate
• D) Provide reassurance to the client
Answer: A) Administer oxygen therapy as prescribed.
Rationale:
Oxygen therapy should be administered first because the primary issue
is the low oxygen saturation (88%), which is critical for the client with
COPD. Administering oxygen will help to increase the oxygen saturation
and relieve the client's symptoms. Calling the provider or increasing the
IV fluid rate can be done after the client's respiratory status is stabilized.
Providing reassurance, while helpful, does not address the immediate
need for oxygen.
2. Question:
A nurse is teaching a client with diabetes about insulin administration.
Which of the following instructions should the nurse include?
• A) "Inject insulin into the same site for each injection."
• B) "Roll the insulin vial between your hands to warm it."
• C) "Inject the insulin into the fatty tissue just under the skin."
, • D) "You should draw up insulin and administer it immediately."
Answer: C) "Inject the insulin into the fatty tissue just under the skin."
Rationale:
Insulin should be injected into the subcutaneous (fatty) tissue, not into
muscle or vein. This allows for proper absorption. Rotating injection
sites is recommended to prevent tissue damage. Insulin should not be
rolled in the hands but rather gently swirled to avoid destroying the
insulin. It is important to draw up insulin and administer it in a timely
manner, but not necessarily immediately after drawing it.
3. Question:
A nurse is caring for a client who has just undergone surgery. The client
is at risk for postoperative pneumonia. Which of the following
interventions is most important to prevent pneumonia?
• A) Administer antibiotics as prescribed
• B) Encourage deep breathing and coughing exercises
• C) Increase the client’s fluid intake
• D) Place the client in a side-lying position
Answer: B) Encourage deep breathing and coughing exercises.
Rationale:
Deep breathing and coughing exercises help to expand the lungs, clear
secretions, and improve ventilation, which are essential in preventing
postoperative pneumonia. While antibiotics may be necessary if an
infection is present, the primary intervention to prevent pneumonia is
to maintain lung function through these exercises. Increasing fluid
,intake and positioning may help, but they are secondary to the need for
lung expansion.
4. Question:
A nurse is assessing a client who is receiving a blood transfusion. The
client suddenly experiences chills, back pain, and a fever. What is the
nurse’s first action?
• A) Stop the blood transfusion immediately
• B) Administer acetaminophen for fever
• C) Increase the IV fluid rate
• D) Notify the healthcare provider
Answer: A) Stop the blood transfusion immediately.
Rationale:
The symptoms described suggest a transfusion reaction, which can be
life-threatening. The nurse's first action is to stop the transfusion
immediately to prevent further complications. After stopping the
transfusion, the nurse should notify the healthcare provider and
provide supportive care as needed, including IV fluids and medications
to manage symptoms.
5. Question:
A nurse is caring for a client with hypertension who is prescribed a
diuretic. What is the most important assessment to monitor during
diuretic therapy?
• A) Blood pressure
, • B) Heart rate
• C) Respiratory rate
• D) Serum potassium levels
Answer: D) Serum potassium levels.
Rationale:
Diuretics can cause a loss of potassium, leading to hypokalemia, which
can cause serious cardiac and muscular issues. The nurse should closely
monitor the client's potassium levels, especially with diuretics like
furosemide. While blood pressure and heart rate are important to
monitor in hypertensive clients, potassium levels are the most critical
for this medication.
6. Question:
A nurse is caring for a client with a fractured femur. The client is in a
cast and reports increasing pain despite receiving prescribed pain
medications. What is the nurse’s first action?
• A) Assess the cast for tightness or pressure
• B) Increase the client’s pain medication dosage
• C) Reassure the client that pain is normal
• D) Encourage the client to perform deep breathing exercises
Answer: A) Assess the cast for tightness or pressure.
Rationale:
Increasing pain in a client with a cast could indicate complications such
as compartment syndrome, which requires immediate intervention. The
nurse should first assess the cast for tightness or signs of pressure,
