1. Which of the following is the priority action for the nurse when
caring for a client with an asthma attack?
• A. Administer prescribed bronchodilator
• B. Obtain a sputum sample for culture
• C. Prepare for intubation
• D. Document vital signs
Answer: A. Administer prescribed bronchodilator
Rationale: The priority action for a client experiencing an asthma attack
is to administer a prescribed bronchodilator, such as albuterol. This
medication helps relax the muscles around the airways and improves
airflow. Obtaining sputum or preparing for intubation are not the
immediate priority actions during an acute asthma attack.
2. A nurse is caring for a client who is post-op day 1 following a total
knee replacement. Which of the following is an expected finding?
• A. Drainage from the surgical site is bright red
• B. The client is experiencing severe pain with movement
• C. The client has decreased mobility in the affected leg
• D. The client’s hemoglobin level is 15 g/dL
Answer: C. The client has decreased mobility in the affected leg
Rationale: On post-op day 1, the client is likely to have decreased
mobility in the affected leg due to pain, swelling, and the healing
process. Bright red drainage might indicate active bleeding, which is not
an expected finding. The client may experience some pain but should
,not have severe pain with movement. A hemoglobin level of 15 g/dL is
normal.
3. Which of the following assessments should a nurse perform first
when caring for a client with a history of heart failure who is
complaining of shortness of breath?
• A. Check oxygen saturation level
• B. Auscultate lung sounds
• C. Monitor blood pressure
• D. Take a temperature
Answer: B. Auscultate lung sounds
Rationale: Auscultating lung sounds is the priority assessment for a
client with a history of heart failure and shortness of breath. This helps
assess for signs of fluid buildup, such as crackles, which are common in
heart failure. Checking oxygen saturation is important, but lung sounds
should be assessed first to determine the cause of the shortness of
breath.
4. A nurse is caring for a client who is receiving a blood transfusion.
Which of the following is the most important to monitor during the
transfusion?
• A. Blood pressure every 15 minutes
• B. Respiratory rate every 30 minutes
• C. Temperature every 15 minutes
• D. Heart rate every 30 minutes
, Answer: C. Temperature every 15 minutes
Rationale: Monitoring the client’s temperature during a blood
transfusion is critical for detecting a transfusion reaction, which can
include fever. Although other vital signs are important, temperature is
the most direct indicator of a transfusion reaction.
5. A nurse is teaching a client with hypertension about lifestyle
modifications. Which of the following statements indicates that the
client understands the teaching?
• A. "I will increase my sodium intake to help balance my blood
pressure."
• B. "I plan to lose 10 pounds over the next month."
• C. "I will decrease my physical activity to reduce my stress."
• D. "I will continue drinking alcohol in moderation every day."
Answer: B. "I plan to lose 10 pounds over the next month."
Rationale: Losing weight is an important lifestyle change for managing
hypertension. The client’s statement about losing 10 pounds is a
realistic goal. Increasing sodium intake, decreasing physical activity, and
drinking alcohol daily are not appropriate recommendations for
hypertension management.
6. A nurse is caring for a client with diabetes mellitus who is receiving
insulin. Which of the following actions is most important for the nurse
to take before administering insulin?
• A. Assess the client’s blood glucose level
caring for a client with an asthma attack?
• A. Administer prescribed bronchodilator
• B. Obtain a sputum sample for culture
• C. Prepare for intubation
• D. Document vital signs
Answer: A. Administer prescribed bronchodilator
Rationale: The priority action for a client experiencing an asthma attack
is to administer a prescribed bronchodilator, such as albuterol. This
medication helps relax the muscles around the airways and improves
airflow. Obtaining sputum or preparing for intubation are not the
immediate priority actions during an acute asthma attack.
2. A nurse is caring for a client who is post-op day 1 following a total
knee replacement. Which of the following is an expected finding?
• A. Drainage from the surgical site is bright red
• B. The client is experiencing severe pain with movement
• C. The client has decreased mobility in the affected leg
• D. The client’s hemoglobin level is 15 g/dL
Answer: C. The client has decreased mobility in the affected leg
Rationale: On post-op day 1, the client is likely to have decreased
mobility in the affected leg due to pain, swelling, and the healing
process. Bright red drainage might indicate active bleeding, which is not
an expected finding. The client may experience some pain but should
,not have severe pain with movement. A hemoglobin level of 15 g/dL is
normal.
3. Which of the following assessments should a nurse perform first
when caring for a client with a history of heart failure who is
complaining of shortness of breath?
• A. Check oxygen saturation level
• B. Auscultate lung sounds
• C. Monitor blood pressure
• D. Take a temperature
Answer: B. Auscultate lung sounds
Rationale: Auscultating lung sounds is the priority assessment for a
client with a history of heart failure and shortness of breath. This helps
assess for signs of fluid buildup, such as crackles, which are common in
heart failure. Checking oxygen saturation is important, but lung sounds
should be assessed first to determine the cause of the shortness of
breath.
4. A nurse is caring for a client who is receiving a blood transfusion.
Which of the following is the most important to monitor during the
transfusion?
• A. Blood pressure every 15 minutes
• B. Respiratory rate every 30 minutes
• C. Temperature every 15 minutes
• D. Heart rate every 30 minutes
, Answer: C. Temperature every 15 minutes
Rationale: Monitoring the client’s temperature during a blood
transfusion is critical for detecting a transfusion reaction, which can
include fever. Although other vital signs are important, temperature is
the most direct indicator of a transfusion reaction.
5. A nurse is teaching a client with hypertension about lifestyle
modifications. Which of the following statements indicates that the
client understands the teaching?
• A. "I will increase my sodium intake to help balance my blood
pressure."
• B. "I plan to lose 10 pounds over the next month."
• C. "I will decrease my physical activity to reduce my stress."
• D. "I will continue drinking alcohol in moderation every day."
Answer: B. "I plan to lose 10 pounds over the next month."
Rationale: Losing weight is an important lifestyle change for managing
hypertension. The client’s statement about losing 10 pounds is a
realistic goal. Increasing sodium intake, decreasing physical activity, and
drinking alcohol daily are not appropriate recommendations for
hypertension management.
6. A nurse is caring for a client with diabetes mellitus who is receiving
insulin. Which of the following actions is most important for the nurse
to take before administering insulin?
• A. Assess the client’s blood glucose level
