Question 1:
A nurse is caring for a client who is post-op following a
laparotomy. Which of the following is the priority nursing
intervention to prevent complications?
A. Encourage deep breathing and coughing every 2 hours.
B. Administer prescribed pain medication every 4 hours.
C. Provide a high-protein diet to promote healing.
D. Ambulate the patient 4 times a day.
Answer: A. Encourage deep breathing and coughing every 2
hours.
Rationale:
Post-operative patients are at risk for atelectasis and
pneumonia due to immobility and anesthesia effects.
Encouraging deep breathing and coughing helps to clear
secretions and prevent respiratory complications, which is the
priority intervention in this case.
Question 2:
A nurse is caring for a client with a history of asthma who is
receiving albuterol via a metered-dose inhaler (MDI). The nurse
should instruct the client to do which of the following to
maximize the effectiveness of the inhaler?
A. Use the inhaler with a spacer.
B. Inhale and hold the breath for 10 seconds.
,C. Wait 30 seconds between inhalations.
D. Exhale forcefully before inhaling the medication.
Answer: A. Use the inhaler with a spacer.
Rationale:
Using a spacer with an MDI ensures that more medication is
delivered to the lungs rather than being deposited in the mouth
or throat. This helps increase the effectiveness of the
medication.
Question 3:
A nurse is assessing a client with a pressure ulcer. Which of the
following is the most important factor in determining the
severity of the ulcer?
A. The size of the ulcer.
B. The amount of exudate present.
C. The stage of the ulcer.
D. The presence of necrotic tissue.
Answer: C. The stage of the ulcer.
Rationale:
The stage of a pressure ulcer is the most important factor in
determining its severity. Staging helps guide the appropriate
treatment and predicts potential complications. The stages are
based on the depth of tissue involvement.
, Question 4:
A nurse is preparing to administer a medication to a client.
Which of the following actions is part of the 6 rights of
medication administration?
A. Ask the client about any allergies.
B. Verify the client's name on the medication order.
C. Document the time of medication administration.
D. Verify the dosage of the medication.
Answer: B. Verify the client's name on the medication order.
Rationale:
One of the "6 rights" is to ensure that the right patient receives
the medication. Verifying the patient's name and matching it
with the medication order is a crucial step in preventing
medication errors.
Question 5:
A nurse is caring for a client with chronic hypertension. The
nurse should instruct the client to monitor which of the
following as a primary indicator of effective blood pressure
control?
A. Weight.
B. Heart rate.
C. Blood pressure readings.
D. Respiratory rate.
A nurse is caring for a client who is post-op following a
laparotomy. Which of the following is the priority nursing
intervention to prevent complications?
A. Encourage deep breathing and coughing every 2 hours.
B. Administer prescribed pain medication every 4 hours.
C. Provide a high-protein diet to promote healing.
D. Ambulate the patient 4 times a day.
Answer: A. Encourage deep breathing and coughing every 2
hours.
Rationale:
Post-operative patients are at risk for atelectasis and
pneumonia due to immobility and anesthesia effects.
Encouraging deep breathing and coughing helps to clear
secretions and prevent respiratory complications, which is the
priority intervention in this case.
Question 2:
A nurse is caring for a client with a history of asthma who is
receiving albuterol via a metered-dose inhaler (MDI). The nurse
should instruct the client to do which of the following to
maximize the effectiveness of the inhaler?
A. Use the inhaler with a spacer.
B. Inhale and hold the breath for 10 seconds.
,C. Wait 30 seconds between inhalations.
D. Exhale forcefully before inhaling the medication.
Answer: A. Use the inhaler with a spacer.
Rationale:
Using a spacer with an MDI ensures that more medication is
delivered to the lungs rather than being deposited in the mouth
or throat. This helps increase the effectiveness of the
medication.
Question 3:
A nurse is assessing a client with a pressure ulcer. Which of the
following is the most important factor in determining the
severity of the ulcer?
A. The size of the ulcer.
B. The amount of exudate present.
C. The stage of the ulcer.
D. The presence of necrotic tissue.
Answer: C. The stage of the ulcer.
Rationale:
The stage of a pressure ulcer is the most important factor in
determining its severity. Staging helps guide the appropriate
treatment and predicts potential complications. The stages are
based on the depth of tissue involvement.
, Question 4:
A nurse is preparing to administer a medication to a client.
Which of the following actions is part of the 6 rights of
medication administration?
A. Ask the client about any allergies.
B. Verify the client's name on the medication order.
C. Document the time of medication administration.
D. Verify the dosage of the medication.
Answer: B. Verify the client's name on the medication order.
Rationale:
One of the "6 rights" is to ensure that the right patient receives
the medication. Verifying the patient's name and matching it
with the medication order is a crucial step in preventing
medication errors.
Question 5:
A nurse is caring for a client with chronic hypertension. The
nurse should instruct the client to monitor which of the
following as a primary indicator of effective blood pressure
control?
A. Weight.
B. Heart rate.
C. Blood pressure readings.
D. Respiratory rate.
