1. A nurse is caring for a 68-year-old client admitted with acute exacerbation of
chronic obstructive pulmonary disease (COPD) who presents with dyspnea,
productive cough with thick sputum, and oxygen saturation of 86% on room
air. The client is using accessory muscles and appears anxious. What is the
nurse’s priority intervention?
Answer: Administer low-flow oxygen as prescribed
2. A nurse is caring for a client 24 hours postoperative following abdominal
surgery who suddenly reports shortness of breath and sharp chest pain. The
client’s oxygen saturation is 88% and heart rate is 118/min. What complication
should the nurse suspect?
Answer: Pulmonary embolism
3. A nurse is caring for a client with type 2 diabetes who becomes shaky,
diaphoretic, and confused before lunch. Blood glucose is 54 mg/dL. What is the
nurse’s first action?
Answer: Administer 15 grams of fast-acting carbohydrate
4. A nurse is caring for a client with heart failure who reports worsening dyspnea
when lying flat and has bilateral crackles. What position should the nurse place
, the client in?
Answer: High-Fowler’s position
5. A nurse is caring for a client with acute pancreatitis who reports severe
epigastric pain radiating to the back and persistent vomiting. What dietary order
should the nurse anticipate initially?
Answer: NPO
6. A nurse is assessing a client with hyperkalemia and notes peaked T waves on
ECG. What is the priority medication to stabilize the heart?
Answer: Calcium gluconate
7. A nurse is caring for a client receiving a blood transfusion who develops fever,
chills, and back pain within 10 minutes of initiation. What is the nurse’s first
action?
Answer: Stop the transfusion
8. A nurse is caring for a client with deep vein thrombosis in the left leg. What
intervention is appropriate to prevent embolization?
Answer: Maintain bed rest and elevate the leg
, 9. A nurse is caring for a client with cirrhosis who becomes increasingly confused
and demonstrates asterixis. What medication should the nurse anticipate
administering?
Answer: Lactulose
10. A nurse is caring for a client with myocardial infarction who reports chest
pain rated 9/10. What assessment must be performed before administering
nitroglycerin?
Answer: Check blood pressure
11. A nurse is caring for a client with chronic kidney disease who has
decreased urine output and elevated potassium levels. What complication is the
client at highest risk for?
Answer: Cardiac dysrhythmias
12. A nurse is caring for a client with suspected stroke who presents with
unilateral weakness and slurred speech. What is the nurse’s priority action?
Answer: Activate the stroke response team
chronic obstructive pulmonary disease (COPD) who presents with dyspnea,
productive cough with thick sputum, and oxygen saturation of 86% on room
air. The client is using accessory muscles and appears anxious. What is the
nurse’s priority intervention?
Answer: Administer low-flow oxygen as prescribed
2. A nurse is caring for a client 24 hours postoperative following abdominal
surgery who suddenly reports shortness of breath and sharp chest pain. The
client’s oxygen saturation is 88% and heart rate is 118/min. What complication
should the nurse suspect?
Answer: Pulmonary embolism
3. A nurse is caring for a client with type 2 diabetes who becomes shaky,
diaphoretic, and confused before lunch. Blood glucose is 54 mg/dL. What is the
nurse’s first action?
Answer: Administer 15 grams of fast-acting carbohydrate
4. A nurse is caring for a client with heart failure who reports worsening dyspnea
when lying flat and has bilateral crackles. What position should the nurse place
, the client in?
Answer: High-Fowler’s position
5. A nurse is caring for a client with acute pancreatitis who reports severe
epigastric pain radiating to the back and persistent vomiting. What dietary order
should the nurse anticipate initially?
Answer: NPO
6. A nurse is assessing a client with hyperkalemia and notes peaked T waves on
ECG. What is the priority medication to stabilize the heart?
Answer: Calcium gluconate
7. A nurse is caring for a client receiving a blood transfusion who develops fever,
chills, and back pain within 10 minutes of initiation. What is the nurse’s first
action?
Answer: Stop the transfusion
8. A nurse is caring for a client with deep vein thrombosis in the left leg. What
intervention is appropriate to prevent embolization?
Answer: Maintain bed rest and elevate the leg
, 9. A nurse is caring for a client with cirrhosis who becomes increasingly confused
and demonstrates asterixis. What medication should the nurse anticipate
administering?
Answer: Lactulose
10. A nurse is caring for a client with myocardial infarction who reports chest
pain rated 9/10. What assessment must be performed before administering
nitroglycerin?
Answer: Check blood pressure
11. A nurse is caring for a client with chronic kidney disease who has
decreased urine output and elevated potassium levels. What complication is the
client at highest risk for?
Answer: Cardiac dysrhythmias
12. A nurse is caring for a client with suspected stroke who presents with
unilateral weakness and slurred speech. What is the nurse’s priority action?
Answer: Activate the stroke response team
