1. Which of the following actions should the nurse take first when responding to a client
who is experiencing chest pain?
A. Administer oxygen to the client.
B. Call for the rapid response team.
C. Assess the client's pain level.
D. Obtain an electrocardiogram (ECG).
Answer: C. Assess the client's pain level.
Rationale: The nurse's first priority is to assess the client’s pain level. This allows the nurse to
identify the severity of the pain and determine the next appropriate interventions.
2. A nurse is caring for a client who is 2 days post-operative following a total hip
replacement. Which of the following actions is most important to prevent complications?
A. Encourage the client to perform deep breathing exercises.
B. Monitor the incision site for signs of infection.
C. Instruct the client to avoid flexing the hip beyond 90 degrees.
D. Administer analgesics as prescribed.
Answer: C. Instruct the client to avoid flexing the hip beyond 90 degrees.
Rationale: After a hip replacement, the nurse should instruct the client to avoid certain
movements to prevent dislocation. Avoiding hip flexion beyond 90 degrees is critical for
maintaining hip joint integrity.
3. A nurse is caring for a client with a diagnosis of heart failure. Which of the following
findings requires immediate intervention?
A. Weight gain of 1.5 kg (3.3 lb) in 2 days.
B. Bilateral pitting edema in the lower extremities.
C. Shortness of breath on exertion.
D. Presence of crackles in the lungs.
Answer: A. Weight gain of 1.5 kg (3.3 lb) in 2 days.
Rationale: Rapid weight gain in a short period of time may indicate fluid retention and
worsening heart failure. This requires immediate intervention to prevent further complications.
, 4. A nurse is caring for a client who is receiving IV fluids and notices the IV site is red,
swollen, and warm. Which action should the nurse take first?
A. Apply a warm compress to the site.
B. Discontinue the IV infusion.
C. Notify the healthcare provider.
D. Change the IV dressing.
Answer: B. Discontinue the IV infusion.
Rationale: The presence of redness, swelling, and warmth indicates phlebitis or infection. The
nurse should first discontinue the IV to prevent further complications and then address the site as
needed.
5. A nurse is preparing to administer a morning dose of insulin to a client with diabetes.
Which of the following actions is most important?
A. Ensure the client has eaten breakfast.
B. Verify the type of insulin being administered.
C. Check the client’s blood glucose level.
D. Ask the client about their activity level.
Answer: C. Check the client’s blood glucose level.
Rationale: Before administering insulin, it is critical to check the client’s blood glucose level to
ensure that the insulin dose is appropriate for their current needs.
6. A nurse is educating a client on how to perform a proper hand hygiene technique. Which
of the following steps should the nurse emphasize?
A. Use an alcohol-based hand sanitizer if hands are visibly soiled.
B. Rub hands together for at least 15 seconds.
C. Turn off the faucet with clean hands after washing.
D. Dry hands with a clean paper towel after washing.
Answer: D. Dry hands with a clean paper towel after washing.
Rationale: Drying hands thoroughly with a clean paper towel is essential to remove any residual
germs. Hands should always be dried with a clean method after hand washing.
who is experiencing chest pain?
A. Administer oxygen to the client.
B. Call for the rapid response team.
C. Assess the client's pain level.
D. Obtain an electrocardiogram (ECG).
Answer: C. Assess the client's pain level.
Rationale: The nurse's first priority is to assess the client’s pain level. This allows the nurse to
identify the severity of the pain and determine the next appropriate interventions.
2. A nurse is caring for a client who is 2 days post-operative following a total hip
replacement. Which of the following actions is most important to prevent complications?
A. Encourage the client to perform deep breathing exercises.
B. Monitor the incision site for signs of infection.
C. Instruct the client to avoid flexing the hip beyond 90 degrees.
D. Administer analgesics as prescribed.
Answer: C. Instruct the client to avoid flexing the hip beyond 90 degrees.
Rationale: After a hip replacement, the nurse should instruct the client to avoid certain
movements to prevent dislocation. Avoiding hip flexion beyond 90 degrees is critical for
maintaining hip joint integrity.
3. A nurse is caring for a client with a diagnosis of heart failure. Which of the following
findings requires immediate intervention?
A. Weight gain of 1.5 kg (3.3 lb) in 2 days.
B. Bilateral pitting edema in the lower extremities.
C. Shortness of breath on exertion.
D. Presence of crackles in the lungs.
Answer: A. Weight gain of 1.5 kg (3.3 lb) in 2 days.
Rationale: Rapid weight gain in a short period of time may indicate fluid retention and
worsening heart failure. This requires immediate intervention to prevent further complications.
, 4. A nurse is caring for a client who is receiving IV fluids and notices the IV site is red,
swollen, and warm. Which action should the nurse take first?
A. Apply a warm compress to the site.
B. Discontinue the IV infusion.
C. Notify the healthcare provider.
D. Change the IV dressing.
Answer: B. Discontinue the IV infusion.
Rationale: The presence of redness, swelling, and warmth indicates phlebitis or infection. The
nurse should first discontinue the IV to prevent further complications and then address the site as
needed.
5. A nurse is preparing to administer a morning dose of insulin to a client with diabetes.
Which of the following actions is most important?
A. Ensure the client has eaten breakfast.
B. Verify the type of insulin being administered.
C. Check the client’s blood glucose level.
D. Ask the client about their activity level.
Answer: C. Check the client’s blood glucose level.
Rationale: Before administering insulin, it is critical to check the client’s blood glucose level to
ensure that the insulin dose is appropriate for their current needs.
6. A nurse is educating a client on how to perform a proper hand hygiene technique. Which
of the following steps should the nurse emphasize?
A. Use an alcohol-based hand sanitizer if hands are visibly soiled.
B. Rub hands together for at least 15 seconds.
C. Turn off the faucet with clean hands after washing.
D. Dry hands with a clean paper towel after washing.
Answer: D. Dry hands with a clean paper towel after washing.
Rationale: Drying hands thoroughly with a clean paper towel is essential to remove any residual
germs. Hands should always be dried with a clean method after hand washing.
