1. A nurse is caring for a client with a history of heart failure who is receiving
digoxin. Which of the following findings should the nurse report to the provider?
a) Apical pulse of 72 bpm
b) Serum potassium level of 3.2 mEq/L
c) Blood pressure of 110/70 mmHg
d) Respiratory rate of 18 breaths per minute
Answer: b) Serum potassium level of 3.2 mEq/L
Rationale: Low potassium levels increase the risk of digoxin toxicity. The nurse should report a
potassium level of 3.2 mEq/L, which is below the normal range of 3.5-5.0 mEq/L.
2. A nurse is caring for a client who has a new prescription for enalapril. Which
of the following should the nurse include in the teaching?
a) "You should take this medication with food."
b) "You may experience increased heart rate."
c) "This medication can cause a persistent dry cough."
d) "This medication can cause your blood pressure to increase."
Answer: c) "This medication can cause a persistent dry cough."
Rationale: A persistent dry cough is a common side effect of ACE inhibitors, such as enalapril.
3. A nurse is caring for a client who is 24 hours post-operative after a total knee
replacement. Which of the following actions should the nurse take first?
a) Administer pain medication.
b) Encourage deep breathing and coughing.
c) Monitor the surgical site for signs of infection.
d) Assess the client's vital signs.
Answer: d) Assess the client's vital signs.
Rationale: The nurse should first assess vital signs to ensure the client is stable post-operatively.
This will help in identifying any signs of complications such as hemorrhage or infection.
4. A nurse is caring for a client who is experiencing a myocardial infarction (MI).
Which of the following interventions should the nurse perform first?
,a) Administer morphine.
b) Administer oxygen.
c) Start an intravenous line.
d) Administer aspirin.
Answer: b) Administer oxygen.
Rationale: Administering oxygen is the priority intervention for a client experiencing an MI to
improve oxygenation to the heart and reduce myocardial damage.
5. A nurse is assessing a client with a suspected stroke. Which of the following
assessments is the priority?
a) Speech patterns.
b) Level of consciousness.
c) Pupillary reaction.
d) Extremity strength.
Answer: b) Level of consciousness.
Rationale: The priority assessment for a client with a suspected stroke is the level of
consciousness, as changes in consciousness can indicate worsening cerebral perfusion and the
need for immediate intervention.
6. A nurse is providing discharge teaching to a client who has a new diagnosis of
type 2 diabetes mellitus. Which of the following statements by the client indicates
a need for further teaching?
a) "I will check my blood sugar levels at least once a day."
b) "I will take my insulin at the same time every day."
c) "I will eat meals at the same time each day to prevent blood sugar fluctuations."
d) "I will only take insulin when I feel my blood sugar is high."
Answer: d) "I will only take insulin when I feel my blood sugar is high."
Rationale: Insulin should be taken as prescribed by the provider, regardless of the client's
symptoms. The client should not wait until they feel their blood sugar is high to administer
insulin.
7. A nurse is caring for a client who has chronic obstructive pulmonary disease
(COPD) and is receiving oxygen via nasal cannula at 2 L/min. The client’s SpO2
is 90%. Which of the following is the priority action?
, a) Increase the oxygen flow rate to 4 L/min.
b) Administer a bronchodilator as prescribed.
c) Notify the provider of the SpO2 level.
d) Reposition the client to improve ventilation.
Answer: d) Reposition the client to improve ventilation.
Rationale: The first priority should be to reposition the client to enhance ventilation and
improve oxygenation before increasing the oxygen flow rate or notifying the provider.
8. A nurse is caring for a client with a diagnosis of appendicitis. Which of the
following findings indicates the need for immediate intervention?
a) Abdominal pain localized to the right lower quadrant.
b) White blood cell count of 15,000/mm3.
c) Sudden relief of pain followed by an increase in abdominal distention.
d) Nausea and vomiting.
Answer: c) Sudden relief of pain followed by an increase in abdominal distention.
Rationale: Sudden relief of pain followed by an increase in abdominal distention could indicate
a ruptured appendix and peritonitis, which requires immediate intervention.
9. A nurse is caring for a client who is 2 days post-operative after a hip
replacement surgery. The client reports difficulty breathing and chest pain.
Which of the following is the priority action?
a) Administer pain medication.
b) Encourage deep breathing exercises.
c) Notify the provider.
d) Monitor vital signs.
Answer: c) Notify the provider.
Rationale: Difficulty breathing and chest pain may indicate a pulmonary embolism, which
requires immediate intervention and provider notification.
10. A nurse is caring for a client with a severe burn injury. Which of the
following assessments is the priority?
a) Pain level.
b) Fluid balance.
digoxin. Which of the following findings should the nurse report to the provider?
a) Apical pulse of 72 bpm
b) Serum potassium level of 3.2 mEq/L
c) Blood pressure of 110/70 mmHg
d) Respiratory rate of 18 breaths per minute
Answer: b) Serum potassium level of 3.2 mEq/L
Rationale: Low potassium levels increase the risk of digoxin toxicity. The nurse should report a
potassium level of 3.2 mEq/L, which is below the normal range of 3.5-5.0 mEq/L.
2. A nurse is caring for a client who has a new prescription for enalapril. Which
of the following should the nurse include in the teaching?
a) "You should take this medication with food."
b) "You may experience increased heart rate."
c) "This medication can cause a persistent dry cough."
d) "This medication can cause your blood pressure to increase."
Answer: c) "This medication can cause a persistent dry cough."
Rationale: A persistent dry cough is a common side effect of ACE inhibitors, such as enalapril.
3. A nurse is caring for a client who is 24 hours post-operative after a total knee
replacement. Which of the following actions should the nurse take first?
a) Administer pain medication.
b) Encourage deep breathing and coughing.
c) Monitor the surgical site for signs of infection.
d) Assess the client's vital signs.
Answer: d) Assess the client's vital signs.
Rationale: The nurse should first assess vital signs to ensure the client is stable post-operatively.
This will help in identifying any signs of complications such as hemorrhage or infection.
4. A nurse is caring for a client who is experiencing a myocardial infarction (MI).
Which of the following interventions should the nurse perform first?
,a) Administer morphine.
b) Administer oxygen.
c) Start an intravenous line.
d) Administer aspirin.
Answer: b) Administer oxygen.
Rationale: Administering oxygen is the priority intervention for a client experiencing an MI to
improve oxygenation to the heart and reduce myocardial damage.
5. A nurse is assessing a client with a suspected stroke. Which of the following
assessments is the priority?
a) Speech patterns.
b) Level of consciousness.
c) Pupillary reaction.
d) Extremity strength.
Answer: b) Level of consciousness.
Rationale: The priority assessment for a client with a suspected stroke is the level of
consciousness, as changes in consciousness can indicate worsening cerebral perfusion and the
need for immediate intervention.
6. A nurse is providing discharge teaching to a client who has a new diagnosis of
type 2 diabetes mellitus. Which of the following statements by the client indicates
a need for further teaching?
a) "I will check my blood sugar levels at least once a day."
b) "I will take my insulin at the same time every day."
c) "I will eat meals at the same time each day to prevent blood sugar fluctuations."
d) "I will only take insulin when I feel my blood sugar is high."
Answer: d) "I will only take insulin when I feel my blood sugar is high."
Rationale: Insulin should be taken as prescribed by the provider, regardless of the client's
symptoms. The client should not wait until they feel their blood sugar is high to administer
insulin.
7. A nurse is caring for a client who has chronic obstructive pulmonary disease
(COPD) and is receiving oxygen via nasal cannula at 2 L/min. The client’s SpO2
is 90%. Which of the following is the priority action?
, a) Increase the oxygen flow rate to 4 L/min.
b) Administer a bronchodilator as prescribed.
c) Notify the provider of the SpO2 level.
d) Reposition the client to improve ventilation.
Answer: d) Reposition the client to improve ventilation.
Rationale: The first priority should be to reposition the client to enhance ventilation and
improve oxygenation before increasing the oxygen flow rate or notifying the provider.
8. A nurse is caring for a client with a diagnosis of appendicitis. Which of the
following findings indicates the need for immediate intervention?
a) Abdominal pain localized to the right lower quadrant.
b) White blood cell count of 15,000/mm3.
c) Sudden relief of pain followed by an increase in abdominal distention.
d) Nausea and vomiting.
Answer: c) Sudden relief of pain followed by an increase in abdominal distention.
Rationale: Sudden relief of pain followed by an increase in abdominal distention could indicate
a ruptured appendix and peritonitis, which requires immediate intervention.
9. A nurse is caring for a client who is 2 days post-operative after a hip
replacement surgery. The client reports difficulty breathing and chest pain.
Which of the following is the priority action?
a) Administer pain medication.
b) Encourage deep breathing exercises.
c) Notify the provider.
d) Monitor vital signs.
Answer: c) Notify the provider.
Rationale: Difficulty breathing and chest pain may indicate a pulmonary embolism, which
requires immediate intervention and provider notification.
10. A nurse is caring for a client with a severe burn injury. Which of the
following assessments is the priority?
a) Pain level.
b) Fluid balance.
