1. A nurse is caring for a client who is recovering from surgery. The
client reports pain as 8/10. Which of the following actions should the
nurse take first?
• A) Administer pain medication.
• B) Reassess pain level in 30 minutes.
• C) Ask the client about their pain tolerance.
• D) Encourage the client to use relaxation techniques.
Answer: A) Administer pain medication.
Rationale: When a client reports severe pain, the nurse should address
the pain immediately by administering prescribed pain medication
before reassessing pain levels, asking about pain tolerance, or
attempting relaxation techniques.
2. A nurse is teaching a client who has chronic hypertension about
managing their blood pressure. Which of the following statements by
the client indicates a need for further teaching?
• A) "I will monitor my blood pressure at home regularly."
• B) "I can continue to eat foods high in sodium as long as I take my
medication."
• C) "I should engage in regular physical activity to help lower my
blood pressure."
• D) "I need to avoid smoking because it can raise my blood
pressure."
Answer: B) "I can continue to eat foods high in sodium as long as I take
my medication."
,Rationale: Clients with hypertension should reduce sodium intake to
help manage blood pressure, regardless of medication use. A diet high
in sodium can counteract the effectiveness of antihypertensive
medications.
3. A nurse is preparing a client for discharge after a hip replacement
surgery. Which of the following actions should the nurse include in the
discharge teaching?
• A) "Avoid using a walker for at least 2 weeks."
• B) "You can resume your normal exercise routine within 1 week."
• C) "Place a chair in the shower to prevent standing for long
periods."
• D) "You may bend your hip past 90 degrees when sitting."
Answer: C) "Place a chair in the shower to prevent standing for long
periods."
Rationale: Clients recovering from hip replacement surgery should
avoid prolonged standing and bending their hips past 90 degrees.
Placing a chair in the shower can help them avoid falls and fatigue.
4. A nurse is caring for a client with a history of asthma. The client is
using a bronchodilator inhaler. Which of the following instructions
should the nurse provide to ensure proper medication use?
• A) "Use the inhaler before meals for the best effect."
• B) "Hold your breath for 10 seconds after inhaling the
medication."
, • C) "Rinse your mouth immediately after using the inhaler."
• D) "Take two inhalations at once to ensure the medication reaches
your lungs."
Answer: B) "Hold your breath for 10 seconds after inhaling the
medication."
Rationale: Holding the breath for 10 seconds after inhaling a
bronchodilator allows the medication to reach deep into the lungs and
increases its effectiveness.
5. A nurse is caring for a client who is receiving intravenous (IV) fluids.
The nurse notes that the client’s IV site is swollen, warm, and
erythematous. What should the nurse do first?
• A) Discontinue the IV infusion and remove the catheter.
• B) Apply a warm compress to the site.
• C) Notify the healthcare provider.
• D) Change the IV tubing.
Answer: A) Discontinue the IV infusion and remove the catheter.
Rationale: The signs of swelling, warmth, and erythema at the IV site
indicate phlebitis or infiltration. The first action is to discontinue the IV
infusion and remove the catheter to prevent further complications.
6. A nurse is teaching a client who is newly diagnosed with diabetes
mellitus. Which of the following statements by the client indicates
that further teaching is necessary?
• A) "I need to monitor my blood sugar levels regularly."
client reports pain as 8/10. Which of the following actions should the
nurse take first?
• A) Administer pain medication.
• B) Reassess pain level in 30 minutes.
• C) Ask the client about their pain tolerance.
• D) Encourage the client to use relaxation techniques.
Answer: A) Administer pain medication.
Rationale: When a client reports severe pain, the nurse should address
the pain immediately by administering prescribed pain medication
before reassessing pain levels, asking about pain tolerance, or
attempting relaxation techniques.
2. A nurse is teaching a client who has chronic hypertension about
managing their blood pressure. Which of the following statements by
the client indicates a need for further teaching?
• A) "I will monitor my blood pressure at home regularly."
• B) "I can continue to eat foods high in sodium as long as I take my
medication."
• C) "I should engage in regular physical activity to help lower my
blood pressure."
• D) "I need to avoid smoking because it can raise my blood
pressure."
Answer: B) "I can continue to eat foods high in sodium as long as I take
my medication."
,Rationale: Clients with hypertension should reduce sodium intake to
help manage blood pressure, regardless of medication use. A diet high
in sodium can counteract the effectiveness of antihypertensive
medications.
3. A nurse is preparing a client for discharge after a hip replacement
surgery. Which of the following actions should the nurse include in the
discharge teaching?
• A) "Avoid using a walker for at least 2 weeks."
• B) "You can resume your normal exercise routine within 1 week."
• C) "Place a chair in the shower to prevent standing for long
periods."
• D) "You may bend your hip past 90 degrees when sitting."
Answer: C) "Place a chair in the shower to prevent standing for long
periods."
Rationale: Clients recovering from hip replacement surgery should
avoid prolonged standing and bending their hips past 90 degrees.
Placing a chair in the shower can help them avoid falls and fatigue.
4. A nurse is caring for a client with a history of asthma. The client is
using a bronchodilator inhaler. Which of the following instructions
should the nurse provide to ensure proper medication use?
• A) "Use the inhaler before meals for the best effect."
• B) "Hold your breath for 10 seconds after inhaling the
medication."
, • C) "Rinse your mouth immediately after using the inhaler."
• D) "Take two inhalations at once to ensure the medication reaches
your lungs."
Answer: B) "Hold your breath for 10 seconds after inhaling the
medication."
Rationale: Holding the breath for 10 seconds after inhaling a
bronchodilator allows the medication to reach deep into the lungs and
increases its effectiveness.
5. A nurse is caring for a client who is receiving intravenous (IV) fluids.
The nurse notes that the client’s IV site is swollen, warm, and
erythematous. What should the nurse do first?
• A) Discontinue the IV infusion and remove the catheter.
• B) Apply a warm compress to the site.
• C) Notify the healthcare provider.
• D) Change the IV tubing.
Answer: A) Discontinue the IV infusion and remove the catheter.
Rationale: The signs of swelling, warmth, and erythema at the IV site
indicate phlebitis or infiltration. The first action is to discontinue the IV
infusion and remove the catheter to prevent further complications.
6. A nurse is teaching a client who is newly diagnosed with diabetes
mellitus. Which of the following statements by the client indicates
that further teaching is necessary?
• A) "I need to monitor my blood sugar levels regularly."
