1. A nurse is assessing a client who is postoperative after a cholecystectomy.
Which of the following findings would indicate a complication?
A) Pain at the incision site
B) Jaundice of the skin and sclera
C) Presence of a wound drain
D) Difficulty moving the right leg
Answer: B) Jaundice of the skin and sclera
Rationale: Jaundice may indicate bile leakage or obstruction, which are potential complications
following a cholecystectomy. Pain at the incision site, presence of a wound drain, and difficulty
moving the right leg are not necessarily abnormal after this procedure.
2. A nurse is caring for a client with a diagnosis of acute pancreatitis. Which of
the following is the priority intervention?
A) Administer pain medications
B) Prepare the client for a CT scan
C) Maintain NPO status
D) Encourage increased fluid intake
Answer: C) Maintain NPO status
Rationale: NPO (nothing by mouth) status is crucial for acute pancreatitis to prevent further
stimulation of pancreatic enzymes and to reduce the risk of complications.
3. A client with cirrhosis develops ascites. The nurse should anticipate which of
the following treatments?
A) Administration of loop diuretics
B) Initiation of oral anticoagulation therapy
C) Increased sodium intake
D) Blood transfusion
Answer: A) Administration of loop diuretics
Rationale: Loop diuretics (such as furosemide) are commonly used to reduce fluid buildup
associated with ascites in clients with cirrhosis. Sodium restriction is also typically advised, not
increased intake.
,4. A client who has undergone a right-sided mastectomy reports numbness and
tingling in the right arm. What is the nurse’s best action?
A) Apply ice to the affected arm
B) Elevate the arm on a pillow
C) Assist the client in performing range-of-motion exercises
D) Document the finding and inform the healthcare provider
Answer: C) Assist the client in performing range-of-motion exercises
Rationale: Numbness and tingling can result from nerve compression or lymphatic drainage
disruption. Range-of-motion exercises help improve circulation and prevent complications such
as lymphedema.
5. A nurse is caring for a client with a new diagnosis of tuberculosis (TB). The
nurse should prioritize which of the following interventions?
A) Implement airborne precautions
B) Administer prescribed antibiotics
C) Educate the client on the importance of hydration
D) Encourage deep breathing exercises
Answer: A) Implement airborne precautions
Rationale: TB is transmitted via airborne particles. Implementing airborne precautions is crucial
to prevent the spread of infection to others.
6. A nurse is caring for a client with hyperthyroidism. Which of the following
findings would the nurse expect?
A) Cold intolerance
B) Weight gain
C) Decreased heart rate
D) Increased blood pressure
Answer: D) Increased blood pressure
Rationale: Hyperthyroidism typically causes symptoms such as weight loss, heat intolerance,
tachycardia, and elevated blood pressure due to increased metabolic activity.
7. A nurse is caring for a client with a myocardial infarction (MI). Which of the
following actions should the nurse take first?
, A) Administer nitroglycerin
B) Administer morphine
C) Administer aspirin
D) Obtain a 12-lead ECG
Answer: D) Obtain a 12-lead ECG
Rationale: Obtaining a 12-lead ECG is the first step in confirming the diagnosis of an MI and
guiding further interventions.
8. A nurse is caring for a client with a tracheostomy. The nurse should monitor
for which of the following complications?
A) Pneumothorax
B) Hypokalemia
C) Tracheal stenosis
D) Hypercalcemia
Answer: C) Tracheal stenosis
Rationale: Tracheal stenosis can occur due to long-term tracheostomy tube placement, leading
to narrowing of the trachea. Regular assessment is necessary to identify early signs of this
complication.
9. A client with heart failure is prescribed furosemide. The nurse should monitor
the client for which of the following potential adverse effects?
A) Hyperkalemia
B) Hypoglycemia
C) Hyponatremia
D) Hypercalcemia
Answer: C) Hyponatremia
Rationale: Furosemide is a loop diuretic that can cause electrolyte imbalances, including
hyponatremia (low sodium levels).
10. A nurse is preparing to administer insulin to a client with diabetes. Which of
the following findings should the nurse address first?
A) A blood glucose level of 160 mg/dL
B) A potassium level of 3.0 mEq/L
Which of the following findings would indicate a complication?
A) Pain at the incision site
B) Jaundice of the skin and sclera
C) Presence of a wound drain
D) Difficulty moving the right leg
Answer: B) Jaundice of the skin and sclera
Rationale: Jaundice may indicate bile leakage or obstruction, which are potential complications
following a cholecystectomy. Pain at the incision site, presence of a wound drain, and difficulty
moving the right leg are not necessarily abnormal after this procedure.
2. A nurse is caring for a client with a diagnosis of acute pancreatitis. Which of
the following is the priority intervention?
A) Administer pain medications
B) Prepare the client for a CT scan
C) Maintain NPO status
D) Encourage increased fluid intake
Answer: C) Maintain NPO status
Rationale: NPO (nothing by mouth) status is crucial for acute pancreatitis to prevent further
stimulation of pancreatic enzymes and to reduce the risk of complications.
3. A client with cirrhosis develops ascites. The nurse should anticipate which of
the following treatments?
A) Administration of loop diuretics
B) Initiation of oral anticoagulation therapy
C) Increased sodium intake
D) Blood transfusion
Answer: A) Administration of loop diuretics
Rationale: Loop diuretics (such as furosemide) are commonly used to reduce fluid buildup
associated with ascites in clients with cirrhosis. Sodium restriction is also typically advised, not
increased intake.
,4. A client who has undergone a right-sided mastectomy reports numbness and
tingling in the right arm. What is the nurse’s best action?
A) Apply ice to the affected arm
B) Elevate the arm on a pillow
C) Assist the client in performing range-of-motion exercises
D) Document the finding and inform the healthcare provider
Answer: C) Assist the client in performing range-of-motion exercises
Rationale: Numbness and tingling can result from nerve compression or lymphatic drainage
disruption. Range-of-motion exercises help improve circulation and prevent complications such
as lymphedema.
5. A nurse is caring for a client with a new diagnosis of tuberculosis (TB). The
nurse should prioritize which of the following interventions?
A) Implement airborne precautions
B) Administer prescribed antibiotics
C) Educate the client on the importance of hydration
D) Encourage deep breathing exercises
Answer: A) Implement airborne precautions
Rationale: TB is transmitted via airborne particles. Implementing airborne precautions is crucial
to prevent the spread of infection to others.
6. A nurse is caring for a client with hyperthyroidism. Which of the following
findings would the nurse expect?
A) Cold intolerance
B) Weight gain
C) Decreased heart rate
D) Increased blood pressure
Answer: D) Increased blood pressure
Rationale: Hyperthyroidism typically causes symptoms such as weight loss, heat intolerance,
tachycardia, and elevated blood pressure due to increased metabolic activity.
7. A nurse is caring for a client with a myocardial infarction (MI). Which of the
following actions should the nurse take first?
, A) Administer nitroglycerin
B) Administer morphine
C) Administer aspirin
D) Obtain a 12-lead ECG
Answer: D) Obtain a 12-lead ECG
Rationale: Obtaining a 12-lead ECG is the first step in confirming the diagnosis of an MI and
guiding further interventions.
8. A nurse is caring for a client with a tracheostomy. The nurse should monitor
for which of the following complications?
A) Pneumothorax
B) Hypokalemia
C) Tracheal stenosis
D) Hypercalcemia
Answer: C) Tracheal stenosis
Rationale: Tracheal stenosis can occur due to long-term tracheostomy tube placement, leading
to narrowing of the trachea. Regular assessment is necessary to identify early signs of this
complication.
9. A client with heart failure is prescribed furosemide. The nurse should monitor
the client for which of the following potential adverse effects?
A) Hyperkalemia
B) Hypoglycemia
C) Hyponatremia
D) Hypercalcemia
Answer: C) Hyponatremia
Rationale: Furosemide is a loop diuretic that can cause electrolyte imbalances, including
hyponatremia (low sodium levels).
10. A nurse is preparing to administer insulin to a client with diabetes. Which of
the following findings should the nurse address first?
A) A blood glucose level of 160 mg/dL
B) A potassium level of 3.0 mEq/L
