WITH 100 COMPLETE DETAILED QUESTIONS AND 100%
CORRECT CERTIFIED ANSWERS WITH VERIFIED RATIONALES
RATED A+ GRADE
A nurse is caring for a client who is 2 hours postoperative
following abdominal surgery. Which assessment finding
requires immediate intervention?
A. Heart rate of 88 beats per minute
B. Temperature of 37.5°C (99.5°F)
C. Oxygen saturation of 89% on room air
D. Blood pressure 118/76 mmHg
Correct Answer: C
Rationale: Oxygen saturation below 90% indicates
hypoxemia and requires immediate intervention such as
oxygen administration and further assessment. Normal
postoperative findings include mild tachycardia, low-
grade fever, and stable blood pressure.
,A client is prescribed furosemide. Which electrolyte
imbalance should the nurse monitor most closely?
A. Hypernatremia
B. Hypokalemia
C. Hypercalcemia
D. Hypermagnesemia
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes
potassium wasting, leading to hypokalemia (low
potassium), which increases the risk of cardiac
dysrhythmias.
A nurse is preparing to insert an indwelling urinary
catheter. Which technique is required for this
procedure?
A. Clean technique
B. Sterile technique
C. Medical asepsis
D. Hand hygiene only
Correct Answer: B
,Rationale: Urinary catheter insertion requires sterile
technique (surgical asepsis) to prevent introducing
bacteria into the bladder and causing a urinary tract
infection.
A client with a history of falls is being discharged home.
Which home modification is most important to prevent
future falls?
A. Install dim lighting to reduce glare
B. Remove loose rugs and secure electrical cords
C. Place frequently used items on high shelves
D. Encourage the client to wear socks without nonslip
soles
Correct Answer: B
Rationale: Removing tripping hazards such as loose rugs,
electrical cords, and clutter is the most important fall
prevention strategy in the home environment.
A nurse is assessing a client's pain using the PQRST
method. Which question assesses the "Quality" of pain?
A. "What makes your pain better or worse?"
, B. "Can you describe your pain?"
C. "Where is your pain located?"
D. "On a scale of 0 to 10, what is your pain level?"
Correct Answer: B
Rationale: PQRST: Provocative/Palliative, Quality
(description such as sharp, dull, burning),
Region/Radiation, Severity, and Timing.
A client is receiving a blood transfusion. Fifteen minutes
after the start, the client reports chills and low back pain.
What is the priority nursing action?
A. Slow the transfusion rate
B. Stop the transfusion immediately
C. Administer acetaminophen
D. Notify the healthcare provider
Correct Answer: B
Rationale: Chills and low back pain may indicate an acute
hemolytic transfusion reaction. The priority is to stop the
transfusion immediately to prevent further
complications.