1. Which action should the nurse take first when providing care for a
client experiencing difficulty breathing?
A. Administer oxygen at 2 L/min via nasal cannula.
B. Assess the client's airway for obstruction.
C. Notify the provider.
D. Raise the head of the bed to a 90-degree angle.
Answer: B. Assess the client's airway for obstruction.
Rationale: The nurse should follow the ABC (airway, breathing,
circulation) priority framework. Assessing the airway is the first step to
determine the cause of the difficulty breathing and take appropriate
actions.
2. A nurse is reinforcing education to a client about the use of an
incentive spirometer. Which statement indicates an understanding of
the teaching?
A. "I should blow into the spirometer as hard as I can."
B. "I should use the spirometer every 2 hours while awake."
C. "The device helps me exhale deeply to remove mucus."
D. "I should stop using the spirometer if I feel lightheaded."
Answer: B. "I should use the spirometer every 2 hours while awake."
Rationale: Regular use of an incentive spirometer helps improve lung
expansion and prevent atelectasis.
3. Which client should the nurse see first during shift change?
A. A client with a potassium level of 5.0 mEq/L.
B. A client receiving IV antibiotics for a urinary tract infection.
,C. A client who had surgery 12 hours ago and reports pain of 7/10.
D. A client who is 2 hours post-op with a new onset of restlessness.
Answer: D. A client who is 2 hours post-op with a new onset of
restlessness.
Rationale: Restlessness could indicate hypoxia, bleeding, or other
complications requiring immediate intervention.
4. A client with a prescription for NPO status reports feeling thirsty.
What is the appropriate action by the nurse?
A. Offer small sips of water.
B. Provide oral care with a moist swab.
C. Allow the client to chew ice chips.
D. Call the provider to change the NPO order.
Answer: B. Provide oral care with a moist swab.
Rationale: Providing oral care maintains comfort without violating NPO
status, which is critical for preventing aspiration.
5. Which laboratory value indicates the need for immediate
intervention?
A. Sodium 138 mEq/L.
B. Hemoglobin 8.0 g/dL.
C. Potassium 4.2 mEq/L.
D. Blood glucose 110 mg/dL.
Answer: B. Hemoglobin 8.0 g/dL.
Rationale: A hemoglobin level of 8.0 g/dL indicates anemia and
potential oxygenation issues requiring immediate attention.
, 6. The nurse is preparing to administer medications through a
nasogastric (NG) tube. Which action should the nurse take?
A. Mix all medications together to save time.
B. Verify placement of the NG tube before administration.
C. Use cold water to flush the NG tube.
D. Administer medications while the client is supine.
Answer: B. Verify placement of the NG tube before administration.
Rationale: Proper tube placement ensures that medications are
delivered to the stomach or small intestine and prevents complications
such as aspiration.
7. A client with heart failure has a prescription for daily weights. What
is the most accurate method to obtain this measurement?
A. Weigh the client in the evening before bed.
B. Weigh the client at the same time every morning after voiding.
C. Use a different scale each day to ensure consistency.
D. Weigh the client with their shoes and clothes on.
Answer: B. Weigh the client at the same time every morning after
voiding.
Rationale: Consistent timing and conditions provide the most accurate
measurement of fluid retention or loss.
8. A nurse is assisting with discharge planning for a client who has a
new colostomy. Which referral is most appropriate?
A. Social worker.
B. Dietitian.
client experiencing difficulty breathing?
A. Administer oxygen at 2 L/min via nasal cannula.
B. Assess the client's airway for obstruction.
C. Notify the provider.
D. Raise the head of the bed to a 90-degree angle.
Answer: B. Assess the client's airway for obstruction.
Rationale: The nurse should follow the ABC (airway, breathing,
circulation) priority framework. Assessing the airway is the first step to
determine the cause of the difficulty breathing and take appropriate
actions.
2. A nurse is reinforcing education to a client about the use of an
incentive spirometer. Which statement indicates an understanding of
the teaching?
A. "I should blow into the spirometer as hard as I can."
B. "I should use the spirometer every 2 hours while awake."
C. "The device helps me exhale deeply to remove mucus."
D. "I should stop using the spirometer if I feel lightheaded."
Answer: B. "I should use the spirometer every 2 hours while awake."
Rationale: Regular use of an incentive spirometer helps improve lung
expansion and prevent atelectasis.
3. Which client should the nurse see first during shift change?
A. A client with a potassium level of 5.0 mEq/L.
B. A client receiving IV antibiotics for a urinary tract infection.
,C. A client who had surgery 12 hours ago and reports pain of 7/10.
D. A client who is 2 hours post-op with a new onset of restlessness.
Answer: D. A client who is 2 hours post-op with a new onset of
restlessness.
Rationale: Restlessness could indicate hypoxia, bleeding, or other
complications requiring immediate intervention.
4. A client with a prescription for NPO status reports feeling thirsty.
What is the appropriate action by the nurse?
A. Offer small sips of water.
B. Provide oral care with a moist swab.
C. Allow the client to chew ice chips.
D. Call the provider to change the NPO order.
Answer: B. Provide oral care with a moist swab.
Rationale: Providing oral care maintains comfort without violating NPO
status, which is critical for preventing aspiration.
5. Which laboratory value indicates the need for immediate
intervention?
A. Sodium 138 mEq/L.
B. Hemoglobin 8.0 g/dL.
C. Potassium 4.2 mEq/L.
D. Blood glucose 110 mg/dL.
Answer: B. Hemoglobin 8.0 g/dL.
Rationale: A hemoglobin level of 8.0 g/dL indicates anemia and
potential oxygenation issues requiring immediate attention.
, 6. The nurse is preparing to administer medications through a
nasogastric (NG) tube. Which action should the nurse take?
A. Mix all medications together to save time.
B. Verify placement of the NG tube before administration.
C. Use cold water to flush the NG tube.
D. Administer medications while the client is supine.
Answer: B. Verify placement of the NG tube before administration.
Rationale: Proper tube placement ensures that medications are
delivered to the stomach or small intestine and prevents complications
such as aspiration.
7. A client with heart failure has a prescription for daily weights. What
is the most accurate method to obtain this measurement?
A. Weigh the client in the evening before bed.
B. Weigh the client at the same time every morning after voiding.
C. Use a different scale each day to ensure consistency.
D. Weigh the client with their shoes and clothes on.
Answer: B. Weigh the client at the same time every morning after
voiding.
Rationale: Consistent timing and conditions provide the most accurate
measurement of fluid retention or loss.
8. A nurse is assisting with discharge planning for a client who has a
new colostomy. Which referral is most appropriate?
A. Social worker.
B. Dietitian.
