Question 1: A nurse is caring for a client who is 24 hours postoperative
after a total hip replacement. The client reports increasing pain in the
hip area. Which of the following actions should the nurse take first?
A) Administer the prescribed pain medication
B) Encourage the client to perform deep breathing exercises
C) Assess the surgical site for signs of infection
D) Encourage the client to use a call light for assistance
Answer: A) Administer the prescribed pain medication
Rationale:
The priority action is to administer pain medication to address the
client's discomfort. Pain management is a critical aspect of recovery,
and it is essential to relieve the client's pain before proceeding with
other assessments or interventions. Once the pain is addressed, the
nurse can assess the surgical site, monitor for infection, and provide
other supportive measures.
Question 2: A nurse is caring for a client with hypertension and is
teaching the client about lifestyle modifications to lower blood
pressure. Which of the following statements by the client indicates a
need for further teaching?
A) "I will reduce my salt intake."
B) "I will exercise 3 times a week."
C) "I will limit my alcohol intake to two drinks per day."
D) "I will monitor my blood pressure at home regularly."
Answer: C) "I will limit my alcohol intake to two drinks per day."
Rationale:
Excessive alcohol consumption can contribute to high blood pressure.
,The recommended limit for alcohol intake for individuals with
hypertension is less than one drink per day for women and two drinks
per day for men. The statement indicates a need for further education
on alcohol's impact on blood pressure.
Question 3: A nurse is preparing to administer a blood transfusion to a
client. Which of the following is the priority action before starting the
transfusion?
A) Check the client's blood pressure and temperature
B) Verify the client’s identity and blood type with another nurse
C) Start an intravenous line with a large gauge needle
D) Administer premedication for allergic reactions
Answer: B) Verify the client’s identity and blood type with another
nurse
Rationale:
The priority before administering a blood transfusion is to ensure the
correct blood product is being given to the correct patient. This is done
by verifying the client's identity and blood type with another nurse to
prevent a transfusion reaction. The other actions are also important but
not as immediate.
Question 4: A nurse is caring for a client who is at risk for developing a
pressure ulcer. Which of the following interventions should the nurse
implement to prevent this complication?
A) Reposition the client every 4 hours
B) Keep the client’s skin dry and free of moisture
, C) Massage bony prominences to increase circulation
D) Apply a heating pad to promote circulation
Answer: B) Keep the client’s skin dry and free of moisture
Rationale:
Keeping the client's skin dry and free of moisture is essential to prevent
skin breakdown. Moisture can increase the risk of pressure ulcers.
Repositioning the client every 2 hours (not 4 hours) is also important.
Massaging bony prominences is not recommended, as it can cause
damage to the tissue. Applying a heating pad is unnecessary and may
increase the risk of skin injury.
Question 5: A nurse is teaching a client with diabetes about blood
glucose monitoring. Which of the following instructions is most
important for the nurse to include?
A) "Wash your hands before testing your blood glucose."
B) "Test your blood glucose immediately after meals."
C) "Use the same finger each time you test."
D) "Apply pressure to the puncture site to stop the bleeding."
Answer: A) "Wash your hands before testing your blood glucose."
Rationale:
Washing hands before testing blood glucose is crucial to ensure
accurate readings, as food or other substances on the hands can alter
results. Testing should be done before meals (not after) to assess
baseline glucose levels. It is recommended to rotate fingers for testing,
and applying pressure to the puncture site is not a standard practice for
stopping bleeding.
after a total hip replacement. The client reports increasing pain in the
hip area. Which of the following actions should the nurse take first?
A) Administer the prescribed pain medication
B) Encourage the client to perform deep breathing exercises
C) Assess the surgical site for signs of infection
D) Encourage the client to use a call light for assistance
Answer: A) Administer the prescribed pain medication
Rationale:
The priority action is to administer pain medication to address the
client's discomfort. Pain management is a critical aspect of recovery,
and it is essential to relieve the client's pain before proceeding with
other assessments or interventions. Once the pain is addressed, the
nurse can assess the surgical site, monitor for infection, and provide
other supportive measures.
Question 2: A nurse is caring for a client with hypertension and is
teaching the client about lifestyle modifications to lower blood
pressure. Which of the following statements by the client indicates a
need for further teaching?
A) "I will reduce my salt intake."
B) "I will exercise 3 times a week."
C) "I will limit my alcohol intake to two drinks per day."
D) "I will monitor my blood pressure at home regularly."
Answer: C) "I will limit my alcohol intake to two drinks per day."
Rationale:
Excessive alcohol consumption can contribute to high blood pressure.
,The recommended limit for alcohol intake for individuals with
hypertension is less than one drink per day for women and two drinks
per day for men. The statement indicates a need for further education
on alcohol's impact on blood pressure.
Question 3: A nurse is preparing to administer a blood transfusion to a
client. Which of the following is the priority action before starting the
transfusion?
A) Check the client's blood pressure and temperature
B) Verify the client’s identity and blood type with another nurse
C) Start an intravenous line with a large gauge needle
D) Administer premedication for allergic reactions
Answer: B) Verify the client’s identity and blood type with another
nurse
Rationale:
The priority before administering a blood transfusion is to ensure the
correct blood product is being given to the correct patient. This is done
by verifying the client's identity and blood type with another nurse to
prevent a transfusion reaction. The other actions are also important but
not as immediate.
Question 4: A nurse is caring for a client who is at risk for developing a
pressure ulcer. Which of the following interventions should the nurse
implement to prevent this complication?
A) Reposition the client every 4 hours
B) Keep the client’s skin dry and free of moisture
, C) Massage bony prominences to increase circulation
D) Apply a heating pad to promote circulation
Answer: B) Keep the client’s skin dry and free of moisture
Rationale:
Keeping the client's skin dry and free of moisture is essential to prevent
skin breakdown. Moisture can increase the risk of pressure ulcers.
Repositioning the client every 2 hours (not 4 hours) is also important.
Massaging bony prominences is not recommended, as it can cause
damage to the tissue. Applying a heating pad is unnecessary and may
increase the risk of skin injury.
Question 5: A nurse is teaching a client with diabetes about blood
glucose monitoring. Which of the following instructions is most
important for the nurse to include?
A) "Wash your hands before testing your blood glucose."
B) "Test your blood glucose immediately after meals."
C) "Use the same finger each time you test."
D) "Apply pressure to the puncture site to stop the bleeding."
Answer: A) "Wash your hands before testing your blood glucose."
Rationale:
Washing hands before testing blood glucose is crucial to ensure
accurate readings, as food or other substances on the hands can alter
results. Testing should be done before meals (not after) to assess
baseline glucose levels. It is recommended to rotate fingers for testing,
and applying pressure to the puncture site is not a standard practice for
stopping bleeding.
