1. A nurse is caring for a patient with a history of hypertension who is
taking a prescribed antihypertensive medication. The nurse should
prioritize which of the following actions when monitoring the
patient’s response to the medication?
A) Monitor the patient's blood pressure.
B) Check the patient's temperature.
C) Assess for changes in the patient's weight.
D) Measure the patient's oxygen saturation.
Answer: A) Monitor the patient's blood pressure.
Rationale: The primary purpose of antihypertensive medication is to
lower the patient's blood pressure. Monitoring the patient's blood
pressure is the most important action to assess the effectiveness of the
medication and avoid potential complications such as hypotension.
2. A nurse is teaching a client about the importance of medication
adherence. Which of the following is an appropriate statement by the
nurse?
A) “It is important to take your medication only when you feel
symptoms.”
B) “You should stop taking the medication if you feel better.”
C) “Take your medication at the same time each day to help you
remember.”
D) “If you forget to take a dose, take two doses the next time.”
Answer: C) “Take your medication at the same time each day to help
you remember.”
Rationale: Consistency in medication adherence is crucial to ensure
therapeutic effectiveness. Taking medications at the same time every
,day can help patients remember to take their medication and avoid
missing doses.
3. A nurse is caring for a patient who is receiving IV morphine for pain.
The nurse should monitor for which of the following adverse effects?
A) Bradycardia
B) Diarrhea
C) Respiratory depression
D) Hyperactive reflexes
Answer: C) Respiratory depression
Rationale: Morphine, an opioid, can cause respiratory depression as a
serious adverse effect. Monitoring respiratory rate and depth is
essential for detecting this complication early and intervening promptly.
4. A nurse is assessing a 60-year-old patient who has a history of
smoking. The nurse is concerned about the patient's risk for lung
cancer. Which of the following screening tests should the nurse expect
to be ordered?
A) Colonoscopy
B) Mammogram
C) Chest X-ray
D) Prostate-specific antigen (PSA) test
Answer: C) Chest X-ray
Rationale: Smoking is a significant risk factor for lung cancer. A chest X-
ray can help identify any lung abnormalities or signs of cancer in
individuals at risk due to smoking.
, 5. A nurse is caring for a patient with a wound infection. Which of the
following interventions should the nurse include in the care plan?
A) Administer a tetanus vaccine if the patient has not had one within 10
years.
B) Apply an alcohol-based hand sanitizer before dressing changes.
C) Change the dressing every 12 hours, regardless of drainage.
D) Clean the wound with hydrogen peroxide daily.
Answer: A) Administer a tetanus vaccine if the patient has not had one
within 10 years.
Rationale: A tetanus vaccine is recommended for patients who have an
open wound, especially if it has been more than 10 years since their last
tetanus vaccination, to prevent the risk of infection. Alcohol-based hand
sanitizers are not effective in preventing infection during wound care;
soap and water should be used instead.
6. A nurse is caring for a 2-year-old child who is receiving a liquid
medication. The nurse should administer the medication using which
of the following methods?
A) In a cup with a straw
B) In a syringe placed directly into the child’s mouth
C) In a teaspoon with the child sitting upright
D) In a bottle with the child lying down
Answer: B) In a syringe placed directly into the child’s mouth
Rationale: Administering liquid medication using an oral syringe directly
into the child’s mouth ensures accurate dosing and helps prevent
taking a prescribed antihypertensive medication. The nurse should
prioritize which of the following actions when monitoring the
patient’s response to the medication?
A) Monitor the patient's blood pressure.
B) Check the patient's temperature.
C) Assess for changes in the patient's weight.
D) Measure the patient's oxygen saturation.
Answer: A) Monitor the patient's blood pressure.
Rationale: The primary purpose of antihypertensive medication is to
lower the patient's blood pressure. Monitoring the patient's blood
pressure is the most important action to assess the effectiveness of the
medication and avoid potential complications such as hypotension.
2. A nurse is teaching a client about the importance of medication
adherence. Which of the following is an appropriate statement by the
nurse?
A) “It is important to take your medication only when you feel
symptoms.”
B) “You should stop taking the medication if you feel better.”
C) “Take your medication at the same time each day to help you
remember.”
D) “If you forget to take a dose, take two doses the next time.”
Answer: C) “Take your medication at the same time each day to help
you remember.”
Rationale: Consistency in medication adherence is crucial to ensure
therapeutic effectiveness. Taking medications at the same time every
,day can help patients remember to take their medication and avoid
missing doses.
3. A nurse is caring for a patient who is receiving IV morphine for pain.
The nurse should monitor for which of the following adverse effects?
A) Bradycardia
B) Diarrhea
C) Respiratory depression
D) Hyperactive reflexes
Answer: C) Respiratory depression
Rationale: Morphine, an opioid, can cause respiratory depression as a
serious adverse effect. Monitoring respiratory rate and depth is
essential for detecting this complication early and intervening promptly.
4. A nurse is assessing a 60-year-old patient who has a history of
smoking. The nurse is concerned about the patient's risk for lung
cancer. Which of the following screening tests should the nurse expect
to be ordered?
A) Colonoscopy
B) Mammogram
C) Chest X-ray
D) Prostate-specific antigen (PSA) test
Answer: C) Chest X-ray
Rationale: Smoking is a significant risk factor for lung cancer. A chest X-
ray can help identify any lung abnormalities or signs of cancer in
individuals at risk due to smoking.
, 5. A nurse is caring for a patient with a wound infection. Which of the
following interventions should the nurse include in the care plan?
A) Administer a tetanus vaccine if the patient has not had one within 10
years.
B) Apply an alcohol-based hand sanitizer before dressing changes.
C) Change the dressing every 12 hours, regardless of drainage.
D) Clean the wound with hydrogen peroxide daily.
Answer: A) Administer a tetanus vaccine if the patient has not had one
within 10 years.
Rationale: A tetanus vaccine is recommended for patients who have an
open wound, especially if it has been more than 10 years since their last
tetanus vaccination, to prevent the risk of infection. Alcohol-based hand
sanitizers are not effective in preventing infection during wound care;
soap and water should be used instead.
6. A nurse is caring for a 2-year-old child who is receiving a liquid
medication. The nurse should administer the medication using which
of the following methods?
A) In a cup with a straw
B) In a syringe placed directly into the child’s mouth
C) In a teaspoon with the child sitting upright
D) In a bottle with the child lying down
Answer: B) In a syringe placed directly into the child’s mouth
Rationale: Administering liquid medication using an oral syringe directly
into the child’s mouth ensures accurate dosing and helps prevent
