1. A nurse is caring for a client with COPD who is experiencing increasing shortness of
breath. Which intervention should the nurse perform first?
Page | 1 A. Administer prescribed corticosteroids
B. Encourage pursed-lip breathing
C. Increase oxygen flow rate to 6 L/min
D. Obtain a chest X-ray
✅ Correct Answer: B
Rationale:
Pursed-lip breathing improves oxygenation and ventilation by preventing airway collapse during
exhalation. It's a non-invasive, immediate intervention the nurse can implement without waiting
for provider orders. Corticosteroids and diagnostics like X-rays are important but not first.
Increasing oxygen flow indiscriminately in COPD can suppress respiratory drive in CO2
retainers.
2. A client with type 1 diabetes reports nausea and vomiting. Which action should the nurse
take first?
A. Administer sliding scale insulin
B. Encourage oral intake of clear fluids
C. Check the client's blood glucose level
D. Notify the provider of symptoms
, ✅ Correct Answer: C
Rationale:
Page | 2 When a diabetic client is nauseous or vomiting, checking the blood glucose is essential to rule
out hypoglycemia or hyperglycemia. Nausea could indicate DKA, which requires urgent care.
Administering insulin or encouraging fluids without assessment may worsen the situation.
Always assess before acting.
3. A nurse prepares to administer digoxin to an elderly client. Which assessment is most
important before administration?
A. Blood pressure
B. Respiratory rate
C. Apical heart rate
D. Level of consciousness
✅ Correct Answer: C
Rationale:
Digoxin can cause bradycardia; therefore, the apical heart rate must be checked for 1 full minute.
If the HR is below 60 bpm, hold the dose and notify the provider. BP and LOC are important but
not specific to digoxin safety. Respiratory rate is unrelated in this context.
, 4. A nurse teaches a client prescribed warfarin. Which client statement indicates the need
for further teaching?
Page | 3 A. "I’ll avoid foods high in vitamin K."
B. "I’ll use a soft toothbrush."
C. "I can take ibuprofen for headaches."
D. "I’ll have regular INR tests."
✅ Correct Answer: C
Rationale:
Ibuprofen increases the risk of bleeding and should be avoided while on warfarin. Clients should
be advised to use acetaminophen for pain instead. All other statements demonstrate accurate
understanding of warfarin precautions.
5. A postpartum client experiences heavy vaginal bleeding and a boggy uterus. What is the
nurse’s priority action?
A. Notify the healthcare provider
B. Administer oxytocin
C. Massage the fundus
D. Insert a second IV line
✅ Correct Answer: C
, Rationale:
A boggy uterus indicates uterine atony, the most common cause of postpartum hemorrhage. The
nurse should immediately massage the uterus to stimulate contraction and reduce bleeding. This
Page | 4
is a first-line, immediate nursing intervention before pharmacologic or provider-dependent
actions.
6. A nurse is reviewing lab results for a client with chronic kidney disease. Which finding is
expected?
A. Elevated calcium
B. Decreased potassium
C. Increased creatinine
D. Low BUN
✅ Correct Answer: C
Rationale:
Clients with chronic kidney disease (CKD) typically have elevated creatinine levels due to
impaired filtration by the kidneys. BUN may also be elevated. Calcium is usually low (not high)
due to poor vitamin D metabolism. Potassium may be elevated, not decreased, due to impaired
renal excretion.
7. A nurse administers IV furosemide to a client. Which finding requires immediate
intervention?
breath. Which intervention should the nurse perform first?
Page | 1 A. Administer prescribed corticosteroids
B. Encourage pursed-lip breathing
C. Increase oxygen flow rate to 6 L/min
D. Obtain a chest X-ray
✅ Correct Answer: B
Rationale:
Pursed-lip breathing improves oxygenation and ventilation by preventing airway collapse during
exhalation. It's a non-invasive, immediate intervention the nurse can implement without waiting
for provider orders. Corticosteroids and diagnostics like X-rays are important but not first.
Increasing oxygen flow indiscriminately in COPD can suppress respiratory drive in CO2
retainers.
2. A client with type 1 diabetes reports nausea and vomiting. Which action should the nurse
take first?
A. Administer sliding scale insulin
B. Encourage oral intake of clear fluids
C. Check the client's blood glucose level
D. Notify the provider of symptoms
, ✅ Correct Answer: C
Rationale:
Page | 2 When a diabetic client is nauseous or vomiting, checking the blood glucose is essential to rule
out hypoglycemia or hyperglycemia. Nausea could indicate DKA, which requires urgent care.
Administering insulin or encouraging fluids without assessment may worsen the situation.
Always assess before acting.
3. A nurse prepares to administer digoxin to an elderly client. Which assessment is most
important before administration?
A. Blood pressure
B. Respiratory rate
C. Apical heart rate
D. Level of consciousness
✅ Correct Answer: C
Rationale:
Digoxin can cause bradycardia; therefore, the apical heart rate must be checked for 1 full minute.
If the HR is below 60 bpm, hold the dose and notify the provider. BP and LOC are important but
not specific to digoxin safety. Respiratory rate is unrelated in this context.
, 4. A nurse teaches a client prescribed warfarin. Which client statement indicates the need
for further teaching?
Page | 3 A. "I’ll avoid foods high in vitamin K."
B. "I’ll use a soft toothbrush."
C. "I can take ibuprofen for headaches."
D. "I’ll have regular INR tests."
✅ Correct Answer: C
Rationale:
Ibuprofen increases the risk of bleeding and should be avoided while on warfarin. Clients should
be advised to use acetaminophen for pain instead. All other statements demonstrate accurate
understanding of warfarin precautions.
5. A postpartum client experiences heavy vaginal bleeding and a boggy uterus. What is the
nurse’s priority action?
A. Notify the healthcare provider
B. Administer oxytocin
C. Massage the fundus
D. Insert a second IV line
✅ Correct Answer: C
, Rationale:
A boggy uterus indicates uterine atony, the most common cause of postpartum hemorrhage. The
nurse should immediately massage the uterus to stimulate contraction and reduce bleeding. This
Page | 4
is a first-line, immediate nursing intervention before pharmacologic or provider-dependent
actions.
6. A nurse is reviewing lab results for a client with chronic kidney disease. Which finding is
expected?
A. Elevated calcium
B. Decreased potassium
C. Increased creatinine
D. Low BUN
✅ Correct Answer: C
Rationale:
Clients with chronic kidney disease (CKD) typically have elevated creatinine levels due to
impaired filtration by the kidneys. BUN may also be elevated. Calcium is usually low (not high)
due to poor vitamin D metabolism. Potassium may be elevated, not decreased, due to impaired
renal excretion.
7. A nurse administers IV furosemide to a client. Which finding requires immediate
intervention?
