1. Which of the following is a priority nursing intervention for a client who is
post-operative following a total hip replacement?
A. Ambulate the client to the bathroom
B. Monitor the client's vital signs every 4 hours
C. Encourage deep breathing and coughing exercises
D. Keep the affected leg adducted
Answer: C. Encourage deep breathing and coughing exercises
Rationale: Post-operative clients are at risk for respiratory complications like pneumonia. Deep
breathing and coughing exercises help prevent atelectasis and promote oxygenation.
2. A client with congestive heart failure is receiving digoxin. Which of the
following laboratory results should the nurse report to the healthcare provider
immediately?
A. Potassium level of 3.2 mEq/L
B. Sodium level of 140 mEq/L
C. BUN of 10 mg/dL
D. Hemoglobin of 12 g/dL
Answer: A. Potassium level of 3.2 mEq/L
Rationale: Low potassium increases the risk of digoxin toxicity, so this value should be
addressed immediately.
3. A nurse is caring for a client with a history of chronic alcohol use who is
admitted with liver cirrhosis. Which of the following assessments is the most
important?
A. Serum albumin levels
B. Bowel sounds
C. Fluid balance
D. Urine output
Answer: C. Fluid balance
Rationale: Cirrhosis often causes ascites and fluid retention, so monitoring fluid balance is
critical to prevent complications like edema or spontaneous bacterial peritonitis.
, 4. A nurse is caring for a client who has acute pancreatitis. The nurse
understands that the client should be placed in which position to relieve pain?
A. Supine with legs flat
B. High-Fowler’s position
C. Side-lying with knees drawn up
D. Trendelenburg position
Answer: C. Side-lying with knees drawn up
Rationale: This position helps to reduce the tension on the abdomen and may alleviate
discomfort associated with pancreatitis.
5. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen via nasal cannula. Which of the following is the priority nursing
assessment?
A. Oxygen saturation level
B. Client’s respiratory rate
C. Breath sounds
D. Skin integrity around the cannula
Answer: A. Oxygen saturation level
Rationale: Monitoring oxygen saturation ensures the client is receiving adequate oxygenation
and helps prevent respiratory acidosis or hypoxemia.
6. Which of the following is the most important action when administering a
blood transfusion?
A. Verify the client’s identity and blood type
B. Administer the transfusion with an IV pump
C. Administer acetaminophen before the transfusion
D. Begin the transfusion immediately upon arrival
Answer: A. Verify the client’s identity and blood type
Rationale: Ensuring proper identification of the client and matching of blood products is crucial
to avoid transfusion reactions.
7. A client with a history of stroke is being discharged. Which statement by the
client indicates a need for further teaching?
post-operative following a total hip replacement?
A. Ambulate the client to the bathroom
B. Monitor the client's vital signs every 4 hours
C. Encourage deep breathing and coughing exercises
D. Keep the affected leg adducted
Answer: C. Encourage deep breathing and coughing exercises
Rationale: Post-operative clients are at risk for respiratory complications like pneumonia. Deep
breathing and coughing exercises help prevent atelectasis and promote oxygenation.
2. A client with congestive heart failure is receiving digoxin. Which of the
following laboratory results should the nurse report to the healthcare provider
immediately?
A. Potassium level of 3.2 mEq/L
B. Sodium level of 140 mEq/L
C. BUN of 10 mg/dL
D. Hemoglobin of 12 g/dL
Answer: A. Potassium level of 3.2 mEq/L
Rationale: Low potassium increases the risk of digoxin toxicity, so this value should be
addressed immediately.
3. A nurse is caring for a client with a history of chronic alcohol use who is
admitted with liver cirrhosis. Which of the following assessments is the most
important?
A. Serum albumin levels
B. Bowel sounds
C. Fluid balance
D. Urine output
Answer: C. Fluid balance
Rationale: Cirrhosis often causes ascites and fluid retention, so monitoring fluid balance is
critical to prevent complications like edema or spontaneous bacterial peritonitis.
, 4. A nurse is caring for a client who has acute pancreatitis. The nurse
understands that the client should be placed in which position to relieve pain?
A. Supine with legs flat
B. High-Fowler’s position
C. Side-lying with knees drawn up
D. Trendelenburg position
Answer: C. Side-lying with knees drawn up
Rationale: This position helps to reduce the tension on the abdomen and may alleviate
discomfort associated with pancreatitis.
5. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen via nasal cannula. Which of the following is the priority nursing
assessment?
A. Oxygen saturation level
B. Client’s respiratory rate
C. Breath sounds
D. Skin integrity around the cannula
Answer: A. Oxygen saturation level
Rationale: Monitoring oxygen saturation ensures the client is receiving adequate oxygenation
and helps prevent respiratory acidosis or hypoxemia.
6. Which of the following is the most important action when administering a
blood transfusion?
A. Verify the client’s identity and blood type
B. Administer the transfusion with an IV pump
C. Administer acetaminophen before the transfusion
D. Begin the transfusion immediately upon arrival
Answer: A. Verify the client’s identity and blood type
Rationale: Ensuring proper identification of the client and matching of blood products is crucial
to avoid transfusion reactions.
7. A client with a history of stroke is being discharged. Which statement by the
client indicates a need for further teaching?
