Practice Test NCLEX Updated 2024
Which of the following is the priority action when caring for a client with a new tracheostomy?
A. Assess the client’s level of consciousness
B. Monitor for signs of infection
C. Ensure the tracheostomy tube is patent
D. Assist with the client’s ambulation
A nurse is teaching a client with type 1 diabetes about insulin administration. Which of the following should the nurse include in the teaching?
A. “You should take your insulin at the same time each day.”
B. “Inject insulin into a site with high muscle mass for quicker absorption.”
C. “Rotate your injection sites to prevent tissue damage.”
D. “You should always inject insulin into the muscle for faster action.”
What is the most appropriate action by a nurse when a client is found unresponsive with a weak pulse and no respirations?
A. Begin chest compressions and administer rescue breaths.
B. Administer oxygen via nasal cannula and monitor vital signs.
C. Call for help and prepare for intubation.
D. Initiate cardiopulmonary resuscitation (CPR).
A client with congestive heart failure is prescribed furosemide (Lasix). What should the nurse monitor for as a potential adverse effect of this medication?
A. Hyperkalemia
B. Hypoglycemia
C. Hypokalemia
D. Hypertension
Which of the following symptoms is most indicative of a complication of a deep vein thrombosis (DVT)?
A. Dull, throbbing pain in the calf
B. Sudden shortness of breath and chest pain
C. Swelling and redness of the affected leg
D. An increase in urinary frequency
A client is admitted to the hospital with a diagnosis of pneumonia. Which of the following findings would indicate a worsening of the client’s condition?
A. Clear lung sounds and productive cough
B. Increased respiratory rate and oxygen saturation of 90%
C. Decreased respiratory rate and fever
D. Productive cough with green sputum and fever
Which of the following interventions is most appropriate for a client experiencing hyperthermia?
A. Increase room temperature and provide warm blankets.
B. Administer antipyretics and encourage fluid intake.
C. Avoid offering fluids to prevent electrolyte imbalance.
D. Keep the client under a heating pad for warmth.
A nurse is caring for a client who has a history of seizures. Which of the following is the most important for the nurse to include in the client’s care plan?
A. Administer the prescribed antiepileptic medications as ordered.
B. Maintain a dark and quiet environment to reduce stimulation.
C. Restrict fluid intake to prevent increased intracranial pressure.
D. Ensure the client has a low-protein diet to prevent seizure activity.
A client is scheduled for a colonoscopy. Which instruction should the nurse include in the pre-procedure teaching?
A. “You will need to avoid any solid foods for 24 hours before the procedure.”
B. “You should take a laxative to ensure your bowels are empty before the procedure.”
C. “Do not take any medications on the day of the procedure.”
D. “You can eat a light breakfast before arriving for the procedure.”
The nurse is caring for a client with diabetes who is experiencing hypoglycemia. Which of the following should the nurse do first?
A. Administer insulin as prescribed.
B. Provide the client with a simple carbohydrate, such as orange juice.
C. Give the client a snack with protein and complex carbohydrates.
D. Recheck the client’s blood glucose level in 15 minutes.
What is the priority nursing action for a client who has just been diagnosed with a myocardial infarction (MI)?
A. Administer prescribed pain medication.
B. Monitor cardiac rhythm and vital signs.
C. Teach the client about lifestyle modifications.
D. Ensure the client is in a sitting position to ease breathing.
A postpartum client is experiencing excessive bleeding after delivery. What is the most important initial action by the nurse?
A. Increase intravenous fluids.
B. Massage the fundus of the uterus.
C. Administer a bolus of oxytocin.
D. Elevate the client’s legs to improve circulation.
A nurse is caring for a client who has been on bed rest for 3 weeks. Which of the following is most important for the nurse to monitor?
A. Skin integrity for pressure ulcers
B. Intake and output
C. Bowel sounds
D. Pulse oximetry
Which of the following best describes the use of a sequential compression device (SCD) in a hospitalized client?
A. To prevent deep vein thrombosis (DVT)
B. To reduce leg swelling caused by heart failure
C. To provide compression for wound healing
D. To improve venous return in the upper extremities
A nurse is caring for a client with severe dehydration. Which of the following assessment findings would be most concerning?
A. Skin turgor that returns slowly
B. Urine output of 30 mL/hour
C. Blood pressure 100/60 mmHg
D. A weight loss of 2 kg over 24 hours
A nurse is caring for a patient with a new tracheostomy. Which action should the nurse take first?
A. Assess the patient’s pain level.
B. Ensure the tracheostomy tube is secure and patent.
C. Encourage the patient to speak.
D. Check for the presence of infection.
Which of the following is the priority intervention for a client experiencing anaphylaxis after an insect sting?
A. Administer a corticosteroid injection.
B. Initiate high-flow oxygen and prepare for intubation.
C. Administer an epinephrine injection.
D. Elevate the client’s legs to promote circulation.
What is the most important action for a nurse when caring for a patient who has a recent myocardial infarction?
A. Encourage the patient to perform deep breathing exercises.
B. Administer prescribed pain medication.
C. Monitor for changes in heart rate and rhythm.
D. Offer the patient a light snack.
A nurse is assessing a client’s urinary output post-surgery. Which output would indicate a need for immediate intervention?
A. 40 mL/hr
B. 20 mL/hr for 2 consecutive hours
C. 60 mL/hr
D. 30 mL/hr
Which instruction should a nurse include when teaching a client with hypertension about lifestyle changes?
A. “Increase your daily salt intake.”
B. “Engage in at least 30 minutes of moderate exercise most days of the week.”
C. “Limit your fluid intake to reduce blood pressure.”
D. “Eat more foods high in saturated fats to maintain energy.”
A client with diabetes is admitted for foot ulcer management. What is the most important aspect of nursing care for this client?
A. Ensure strict blood glucose monitoring.
B. Apply a moist dressing to the ulcer.
C. Assess for signs of infection in the affected foot.
D. Instruct the client to keep the leg elevated at all times.
Which of the following findings should a nurse consider a priority when assessing a postpartum client?
A. Decreased urinary output.
B. Positive Homan’s sign.
C. Temperature of 37.5°C (99.5°F).
D. Fundus located at the umbilicus.
A nurse is teaching a client with hypertension about the importance of medication adherence. Which statement indicates that the client needs further teaching?
A. “I should take my blood pressure medication at the same time each day.”
B. “It’s okay to stop taking my medication if my blood pressure is normal.”
C. “I need to monitor my blood pressure regularly.”
D. “I should report any new or worsening symptoms to my doctor.”
Which of the following findings indicates that a client receiving chemotherapy is developing neutropenia?
A. A white blood cell count of 5,000/mm³.
B. Increased bruising and bleeding.
C. A temperature of 38.1°C (100.6°F).
D. White patches in the mouth.
What is the primary nursing intervention for a client who is experiencing severe anxiety?
A. Administer prescribed anti-anxiety medication.
B. Encourage the client to express their feelings.
C. Initiate deep breathing exercises and offer relaxation techniques.
D. Provide distractions such as TV and music.
A client who has been receiving heparin for 2 days is found to have an activated partial thromboplastin time (aPTT) of 100 seconds. What is the nurse’s priority action?
A. Increase the heparin infusion rate.
B. Hold the next dose of heparin and notify the healthcare provider.
C. Administer vitamin K as prescribed.
D. Continue to monitor the aPTT without any change.
Which client statement indicates the need for further teaching about self-care for an ulcerative colitis flare-up?
A. “I should increase my fluid intake during a flare.”
B. “It’s okay to eat high-fiber foods when I’m feeling better.”
C. “I need to avoid dairy products during a flare-up.”
D. “I can take nonsteroidal anti-inflammatory drugs for pain relief.”
What is the most effective way for a nurse to promote early ambulation in a postoperative client?
A. Ensure that the client has pain medication before ambulating.
B. Offer to assist the client with ambulation as soon as possible.
C. Wait until the client feels ready to get out of bed on their own.
D. Provide an incentive spirometer for use before ambulation.
A client has been admitted with suspected appendicitis. Which assessment finding is most concerning?
A. Pain that is relieved by bending the knees.
B. A temperature of 38.3°C (100.9°F).
C. Pain that shifts from the right lower quadrant to the epigastric area.
D. Nausea and vomiting.
Which of the following is a key indicator that a client with chronic kidney disease (CKD) is experiencing fluid overload?
A. Decreased blood pressure.
B. Increased respiratory rate.
C. Peripheral edema and crackles in the lungs.
D. Increased hematocrit level.
A nurse is caring for a patient with a chest tube. Which of the following findings should be reported to the healthcare provider?
A. Intermittent bubbling in the water seal chamber.
B. Continuous bubbling in the water seal chamber.
C. The presence of tidaling in the water seal chamber.
D. A decrease in drainage in the collection chamber.
Which of the following is an appropriate nursing action for a client receiving a blood transfusion who begins to exhibit chills, fever, and back pain?
A. Increase the rate of the transfusion.
B. Stop the transfusion and maintain intravenous access with normal saline.
C. Continue to monitor the client and assess vital signs.
D. Administer acetaminophen for fever.
A client with cirrhosis is at risk for developing which complication due to decreased liver function?
A. Hyperglycemia
B. Hypoglycemia
C. Hyperkalemia
D. Hypokalemia
Which finding is most concerning in a client who is post-operative following a hip replacement?
A. Mild swelling at the surgical site.
B. A temperature of 37.2°C (99°F).
C. Decreased peripheral pulses in the affected leg.
D. Pain controlled with prescribed analgesics.
A nurse is assessing a client for potential complications related to prolonged bed rest. Which of the following is the most significant sign of a deep vein thrombosis (DVT)?
A. Mild pain in the calf that increases with walking.
B. Warmth, swelling, and redness in one leg.
C. Cramping in both legs during sleep.
D. Bilateral leg edema.
A nurse is educating a client with asthma on how to properly use a metered-dose inhaler (MDI). Which statement by the client indicates a need for further teaching?
A. “I should shake the inhaler before using it.”
B. “I will hold my breath for 10 seconds after inhaling the medication.”
C. “I should exhale forcefully before using the inhaler.”
D. “I will wait 30 seconds before using a second puff of medication.”
Which of the following interventions is most appropriate for a client who has been diagnosed with a stage II pressure ulcer?
A. Apply a wet-to-dry dressing.
B. Use an antibacterial ointment and a dry dressing.
C. Apply a hydrocolloid dressing.
D. Administer an analgesic before dressing changes.
A client is being treated for heart failure. Which of the following signs indicates the need for immediate intervention?
A. Weight gain of 0.5 kg (1 lb) in 24 hours.
B. Increased coughing at night.
C. Reduced urine output during the day.
D. Edema in the lower extremities.
A nurse is caring for a client with a fever of 39.5°C (103.1°F). What should the nurse do first?
A. Administer an antipyretic.
B. Offer fluids and encourage hydration.
C. Place the client in a cooling bath.
D. Assess for signs of dehydration.
Which of the following is the most important consideration when administering intravenous (IV) potassium to a client?
A. It should be given as a bolus for rapid action.
B. The infusion rate should not exceed 10 mEq/hour without cardiac monitoring.
C. The potassium should be diluted with sterile water before infusion.
D. The IV site should be monitored every 30 minutes for signs of infiltration.
A client with diabetes mellitus is admitted with a blood glucose level of 500 mg/dL and signs of ketoacidosis. Which of the following actions should the nurse take first?
A. Administer a dose of long-acting insulin.
B. Initiate an intravenous (IV) infusion of normal saline.
C. Provide the client with a meal containing complex carbohydrates.
D. Give the client a dose of oral glucose.
A nurse is caring for a client who has been placed on continuous cardiac monitoring. Which of the following is the best indicator of ventricular arrhythmias?
A. P wave changes.
B. ST segment elevation.
C. QRS complex widening.
D. T wave inversion.
When assessing a client with a pressure ulcer, the nurse notes that the ulcer has a red base with a yellowish exudate. The most appropriate dressing choice is:
A. A hydrocolloid dressing.
B. A dry, sterile dressing.
C. An absorbent foam dressing.
D. A transparent film dressing.
A nurse is reviewing the lab results of a client receiving chemotherapy. Which of the following results would be most concerning?
A. Hemoglobin of 12.5 g/dL.
B. Platelet count of 90,000/mm³.
C. White blood cell count of 4,000/mm³.
D. Potassium level of 3.5 mEq/L.
Which statement by a client being taught about oral contraceptive use indicates the need for further teaching?
A. “I will take my pill at the same time each day.”
B. “I need to stop taking the pill if I experience severe headaches.”
C. “I should report any unusual leg pain or swelling to my doctor.”
D. “I can take antibiotics with my oral contraceptive without any effect.”
A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy. What is the nurse’s priority concern?
A. The oxygen flow rate should not exceed 2 L/min.
B. The client should not be placed in a sitting position.
C. The client must be monitored for signs of hypercapnia.
D. The client should avoid using a humidifier with oxygen therapy.
What is the most appropriate initial nursing action for a client with a suspected spinal cord injury?
A. Apply a cervical collar.
B. Assist the client to sit up to assess spinal stability.
C. Move the client to a different bed for further assessment.
D. Take the client’s vital signs to monitor for changes.
A nurse is caring for a client who is receiving IV fluids and notes that the site is red, swollen, and warm to the touch. What is the best action?
A. Continue to monitor the site for further changes.
B. Remove the IV and apply warm compresses.
C. Administer prescribed antibiotics.
D. Secure the IV with additional tape.
A nurse is caring for a client after a laparoscopic cholecystectomy. Which of the following is the most common post-operative complication?
A. Bile leak.
B. Atelectasis.
C. Wound infection.
D. Deep vein thrombosis (DVT).
Which action should a nurse take to prevent complications in a client who is immobile and at risk for deep vein thrombosis (DVT)?
A. Keep the legs elevated at all times.
B. Encourage the client to perform isometric exercises frequently.
C. Massage the calf muscles to promote circulation.
D. Apply compression stockings as ordered.
A nurse is caring for a client with a suspected myocardial infarction (MI). Which of the following symptoms is most concerning for an MI?
A. Lightheadedness and dizziness.
B. Pain radiating down the left arm.
C. Headache and blurred vision.
D. A sudden increase in blood pressure.
Which assessment finding is the most indicative of a potential complication following a total knee replacement?
A. Pain with slight swelling at the surgical site.
B. Difficulty in bending the knee post-surgery.
C. The presence of warmth and redness above the knee.
D. Unilateral swelling and pain in the calf of one leg.
What is the most appropriate nursing action for a client with chronic pain who is prescribed long-acting opioids?
A. Monitor respiratory rate and level of consciousness regularly.
B. Encourage the client to take the medication on an as-needed basis.
C. Discourage the use of non-pharmacological pain relief methods.
D. Increase the dosage of opioids if the client reports pain.
A nurse is teaching a client with heart failure about the importance of weighing themselves daily. Which statement indicates that the client understands?
A. “I will weigh myself in the morning after eating breakfast.”
B. “I should weigh myself at the same time each day, preferably in the morning before eating or drinking.”
C. “I only need to weigh myself once a week.”
D. “I should weigh myself after lunch for the most accurate result.”
A nurse is caring for a client with a diagnosis of pneumonia. Which of the following interventions is the priority?
A. Encouraging the client to cough and deep breathe.
B. Administering prescribed antibiotics.
C. Monitoring oxygen saturation levels.
D. Ensuring the client is hydrated with IV fluids.
Which of the following instructions should a nurse give to a client who has been prescribed a potassium-sparing diuretic?
A. “Avoid eating foods high in potassium.”
B. “Limit fluid intake to prevent fluid retention.”
C. “Check your blood pressure regularly.”
D. “Take the medication with a meal to reduce gastrointestinal upset.”
What is the most appropriate nursing intervention for a client experiencing acute anxiety during an emergency situation?
A. Offer them a sedative as soon as possible.
B. Encourage deep breathing and use grounding techniques.
C. Ask them to step outside for fresh air.
D. Leave them alone to collect their thoughts.
Which client condition should a nurse prioritize for immediate intervention?
A. A client with a hemoglobin level of 12 g/dL.
B. A client reporting nausea after chemotherapy.
C. A client with a Glasgow Coma Scale (GCS) score of 10.
D. A client with a blood pressure of 130/80 mmHg.
A nurse is assessing a client with a history of seizures. Which of the following interventions is most important to include in the care plan?
A. Place a tongue blade in the client’s mouth during a seizure.
B. Ensure the client’s bed is positioned safely with side rails up.
C. Keep the client’s room dark and quiet.
D. Administer antiepileptic drugs at the first sign of a seizure.
A client receiving chemotherapy reports severe mouth pain and difficulty swallowing. Which is the most appropriate nursing intervention?
A. Recommend the use of an over-the-counter mouthwash.
B. Provide the client with a soft diet and encourage hydration.
C. Administer a high dose of a pain reliever.
D. Suggest avoiding any foods or drinks.
A client with advanced chronic kidney disease (CKD) is being treated with erythropoietin. Which lab value should the nurse monitor closely to prevent complications?
A. Serum calcium levels.
B. Hemoglobin and hematocrit levels.
C. Blood glucose levels.
D. Potassium levels.
Which of the following is the priority intervention for a client with a suspected tension pneumothorax?
A. Administer high-flow oxygen via face mask.
B. Insert a chest tube.
C. Perform needle decompression.
D. Place the client in a supine position.
A nurse is caring for a post-operative client who has been receiving morphine for pain management. Which of the following signs would indicate respiratory depression?
A. Respiratory rate of 16 breaths per minute.
B. Slow, shallow respirations at 10 breaths per minute.
C. A slight increase in the respiratory rate.
D. Audible wheezing and coughing.
A client who has been prescribed warfarin for atrial fibrillation should be advised to avoid which of the following foods?
A. Leafy green vegetables.
B. Dairy products.
C. Lean meats.
D. High-sodium foods.
Which statement by a client taking a selective serotonin reuptake inhibitor (SSRI) indicates a need for further teaching?
A. “I should take this medication at the same time every day.”
B. “I can stop taking the medication if I feel better.”
C. “It may take a few weeks before I feel the full effects.”
D. “I should avoid alcohol while taking this medication.”
A nurse is preparing to care for a client diagnosed with bacterial meningitis. Which personal protective equipment (PPE) should the nurse use?
A. Mask and gloves.
B. Full gown, gloves, and N95 respirator.
C. Surgical mask and face shield.
D. Regular gloves and gown.
A nurse is assessing a client who has been on bed rest for two weeks. Which finding would be most concerning?
A. Decreased muscle strength in the lower extremities.
B. Mild swelling in the feet after standing.
C. Red, warm area on the calf of one leg.
D. A slight decrease in appetite.
Which client condition should the nurse report immediately to the healthcare provider?
A. A client with chronic asthma who reports mild shortness of breath.
B. A client with heart failure and a sudden increase in weight by 3 pounds in one day.
C. A client with hypertension and a blood pressure reading of 140/90 mmHg.
D. A client with diabetes mellitus and a fasting blood sugar of 130 mg/dL.
What is the priority nursing action for a client diagnosed with hypernatremia?
A. Administer diuretics as ordered.
B. Offer the client high-sodium foods.
C. Encourage oral fluid intake.
D. Monitor blood pressure frequently.
Which of the following findings in a client receiving diuretic therapy should prompt immediate nursing intervention?
A. Potassium level of 3.2 mEq/L.
B. A slight decrease in blood pressure.
C. The client reports increased thirst.
D. The client reports feeling fatigued but has normal electrolyte levels.
A client with a history of heart failure presents with increased shortness of breath, crackles in the lungs, and peripheral edema. Which intervention should the nurse prioritize?
A. Administer a prescribed diuretic.
B. Encourage the client to ambulate frequently.
C. Increase the client’s fluid intake.
D. Teach deep breathing exercises.
A nurse is assessing a client who has been taking prednisone for several weeks. Which of the following findings should the nurse report to the provider?
A. Elevated blood glucose levels.
B. Weight loss of 2 pounds.
C. Mild stomach discomfort.
D. Increased energy and activity level.
Which action should the nurse take for a client who has a positive stool guaiac test?
A. Schedule a colonoscopy immediately.
B. Encourage increased fiber intake.
C. Monitor for signs of gastrointestinal bleeding.
D. Advise the client to rest for a few days.
A nurse is caring for a client who is receiving IV antibiotics. Which of the following signs indicates a potential allergic reaction?
A. Increased thirst and frequent urination.
B. Red, itchy rash and swelling of the lips.
C. Muscle cramping and nausea.
D. Low-grade fever and chills.
A client is receiving total parenteral nutrition (TPN). Which action by the nurse is essential to reduce the risk of complications?
A. Place the TPN bag at room temperature before infusing.
B. Monitor blood glucose levels closely.
C. Avoid using an infusion pump.
D. Check the client’s electrolyte levels once a week.
What is the priority teaching for a client starting on antihypertensive medication?
A. “Avoid all foods high in sodium.”
B. “You should monitor your blood pressure at home regularly.”
C. “Stop taking your medication if you experience dizziness.”
D. “Increase your physical activity immediately.”
A nurse is caring for a client with a closed head injury. Which of the following findings should be reported immediately?
A. Slurred speech and drowsiness.
B. Clear nasal discharge.
C. Unequal pupil size.
D. Persistent headache.
A client is on a low-sodium diet to control hypertension. Which of the following foods is most appropriate for the client to eat?
A. Canned soup.
B. Fresh fruits and vegetables.
C. Processed cheese.
D. Smoked meats.
The nurse is caring for a client who has been prescribed enalapril for hypertension. Which side effect should the nurse monitor for?
A. Hyperkalemia.
B. Hypoglycemia.
C. Tachycardia.
D. Weight gain.
What is the most important assessment for a nurse to perform on a client receiving a blood transfusion?
A. Assessing lung sounds every 2 hours.
B. Monitoring for signs of an allergic reaction during the transfusion.
C. Checking the client’s dietary history.
D. Measuring the client’s urine output every 6 hours.
A nurse is caring for a client who has a wound infection and is receiving antibiotics. Which lab result would be most concerning?
A. White blood cell (WBC) count of 9,000/mm³.
B. Blood culture positive for Staphylococcus aureus.
C. Serum creatinine of 1.2 mg/dL.
D. Blood pressure of 118/76 mmHg.
A client is being treated for dehydration and has been on a rehydration solution for 12 hours. What indicates that the client’s condition is improving?
A. Increased thirst and dry skin.
B. Normalized vital signs and improved skin turgor.
C. Decreased urine output.
D. Edema in the lower extremities.
A client with an anxiety disorder is prescribed lorazepam. Which of the following should the nurse include in the teaching plan?
A. “You can drive after taking this medication as long as you don’t feel sleepy.”
B. “Avoid taking this medication with alcohol or other CNS depressants.”
C. “Take the medication at bedtime to avoid daytime drowsiness.”
D. “This medication should be stopped abruptly if you feel better.”
A nurse is caring for a client with a suspected diagnosis of appendicitis. Which symptom is most characteristic of appendicitis?
A. Sharp, crampy pain in the lower left quadrant.
B. Dull, aching pain around the navel that shifts to the right lower quadrant.
C. Severe, stabbing pain that radiates to the back.
D. Pain that decreases with movement.
What is the most important action when caring for a client with an indwelling urinary catheter?
A. Regularly repositioning the catheter to prevent kinking.
B. Keeping the drainage bag above the level of the bladder.
C. Ensuring that the catheter is secured properly to avoid tension.
D. Encouraging the client to increase fluid intake.
A client with diabetes mellitus asks the nurse why they need to check their blood glucose levels regularly. What is the most appropriate response?
A. “It helps to monitor the effects of your diet on your blood sugar levels.”
B. “It ensures you are not taking too much medication.”
C. “It helps identify low blood sugar levels before they become serious.”
D. “It provides a way for you to skip insulin doses when levels are low.”
A client is diagnosed with C. difficile colitis. What type of precautions should the nurse implement?
A. Airborne precautions.
B. Contact precautions.
C. Droplet precautions.
D. Standard precautions only.
A nurse is assessing a client who is at risk for pressure ulcers. Which of the following is the most significant risk factor?
A. Age over 65 years.
B. Recent weight loss.
C. Limited mobility.
D. Incontinence.
What is the priority intervention for a client who has just been diagnosed with a tension pneumothorax?
A. Administering a bronchodilator.
B. Preparing the client for chest tube insertion.
C. Administering oxygen via nasal cannula.
D. Initiating cardiac monitoring.
A nurse is assessing a client with chronic liver disease. Which finding should be reported immediately to the healthcare provider?
A. Increased appetite and weight gain.
B. Jaundice and dark urine.
C. Mild fatigue and generalized itching.
D. Bruising and prolonged clotting time.
A client who recently underwent a hip replacement surgery is at risk for developing a deep vein thrombosis (DVT). Which intervention should the nurse prioritize?
A. Encourage ambulation as soon as possible.
B. Administer prescribed pain medication before mobilization.
C. Apply a heating pad to the affected leg.
D. Monitor the client’s vital signs every hour.
A nurse is teaching a client with hypertension about lifestyle changes. Which statement indicates the client needs further teaching?
A. “I should aim for at least 30 minutes of exercise most days of the week.”
B. “I can still eat fast food as long as I choose a salad.”
C. “I will try to reduce my intake of high-sodium foods.”
D. “I should monitor my blood pressure at home regularly.”
What should the nurse do first when caring for a client with severe hypoglycemia?
A. Administer insulin.
B. Provide the client with a glucose tablet or juice.
C. Monitor the client’s vital signs.
D. Contact the healthcare provider.
Which assessment finding would be most concerning for a client on long-term corticosteroid therapy?
A. Insomnia and weight gain.
B. Hyperglycemia and edema.
C. Increased appetite and a positive skin test for tuberculosis.
D. Fatigue and muscle weakness.
A client is receiving a unit of blood. Which of the following is the most critical action the nurse should take?
A. Infuse the blood at a slow rate.
B. Monitor for signs of a transfusion reaction.
C. Warm the blood before infusion.
D. Ensure the blood is infused within 4 hours.
A nurse is assessing a client who has been diagnosed with hypothyroidism. Which of the following findings is most expected?
A. Increased appetite and weight loss.
B. Fine, brittle hair and hot, moist skin.
C. Fatigue, dry skin, and weight gain.
D. Restlessness and tremors.
A client presents to the ED with chest pain and diaphoresis. Which priority action should the nurse take?
A. Obtain a 12-lead ECG.
B. Administer a dose of nitroglycerin.
C. Perform a physical examination of the chest.
D. Administer pain medication as ordered.
A nurse is caring for a client with a nasogastric (NG) tube who has developed aspiration pneumonia. Which action is most important?
A. Keep the head of the bed elevated at least 30 degrees.
B. Administer antibiotics as prescribed.
C. Provide oxygen therapy as needed.
D. Monitor the client’s temperature every 4 hours.
A client who is post-operative from a cholecystectomy is experiencing severe pain and has vomited twice. What should the nurse do first?
A. Administer the prescribed pain medication.
B. Assess the surgical site for signs of infection.
C. Encourage the client to drink fluids.
D. Check the client’s vital signs.
Which of the following findings in a client receiving heparin therapy indicates a potential adverse effect?
A. Increased appetite and mild nausea.
B. A sudden decrease in the platelet count.
C. Mild bruising at the injection site.
D. Pain and swelling in the lower extremities.
A client has been admitted to the hospital with suspected appendicitis. Which of the following signs would support this diagnosis?
A. Pain located in the lower left quadrant of the abdomen.
B. Pain that radiates to the lower back.
C. Pain that starts near the navel and moves to the right lower quadrant.
D. Dull, aching pain that worsens with movement.
Which action should the nurse take for a client receiving radiation therapy?
A. Apply a warm compress to the affected area.
B. Avoid using lotions or creams on the radiation site.
C. Keep the skin clean and dry.
D. Massage the skin with oil to prevent dryness.
A nurse is providing discharge instructions to a client who had a myocardial infarction (MI). Which statement indicates the client understands the teaching?
A. “I should avoid walking or doing any exercise for the next 6 weeks.”
B. “I can drink up to 2 cups of alcohol per day.”
C. “I will take my prescribed medications as directed, even if I feel fine.”
D. “I should only take aspirin if I have chest pain.”
A client with schizophrenia is prescribed clozapine. What side effect should the nurse monitor for closely?
A. High blood pressure.
B. Hyperglycemia and seizures.
C. Dehydration and dry mouth.
D. Excessive drowsiness and fatigue.
A client is experiencing a severe allergic reaction to a bee sting. What is the priority nursing action?
A. Apply a cold compress to the affected area.
B. Administer prescribed antihistamines.
C. Assess the client’s airway, breathing, and circulation (ABCs).
D. Give the client a pain reliever for discomfort.
Which statement by a client receiving chemotherapy indicates a need for further teaching?
A. “I should avoid large crowds to reduce the risk of infection.”
B. “I can continue to work if I don’t feel too tired.”
C. “I will take my prescribed medication as directed.”
D. “I can take herbal supplements to help with nausea.”
A nurse is caring for a client with a closed head injury. Which assessment finding is most concerning?
A. A Glasgow Coma Scale (GCS) score of 15.
B. Clear drainage from the nose.
C. The client’s pupils are equal and reactive to light.
D. A headache that is relieved by acetaminophen.
What should the nurse do first when a client is found unresponsive?
A. Call for help.
B. Check the client’s vital signs.
C. Perform chest compressions.
D. Assess the client’s airway and breathing.
A nurse is teaching a client about the use of an inhaler for asthma. Which of the following instructions is most important?
A. “Rinse your mouth after each use to prevent dry mouth.”
B. “You can use the inhaler as needed for quick relief.”
C. “Make sure to use your inhaler before exercising.”
D. “Shake the inhaler vigorously before each use.”
A client with hypertension is prescribed lisinopril. Which of the following side effects should the nurse inform the client about?
A. Cough and dizziness.
B. Increased appetite and weight gain.
C. Diarrhea and fever.
D. Rapid heartbeat and palpitations.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. What is the priority assessment for this client?
A. Oxygen saturation levels.
B. Skin color and temperature.
C. Lung sounds.
D. Heart rate and rhythm.
A nurse is teaching a client with diabetes about insulin administration. Which statement indicates correct understanding?
A. “I should inject insulin into the muscle for faster absorption.”
B. “I can use the same injection site repeatedly without rotating.”
C. “I should rotate the injection site to prevent tissue damage.”
D. “Insulin can be stored at room temperature for up to 2 weeks.”
A nurse is assessing a postpartum client. Which finding requires immediate follow-up?
A. A firm, contracted uterus.
B. A blood pressure reading of 140/90 mmHg.
C. A temperature of 99.5°F (37.5°C).
D. Excessive vaginal bleeding that saturates one pad in 1 hour.
A client with tuberculosis (TB) is prescribed rifampin. Which side effect should the nurse educate the client about?
A. Yellowing of the skin and eyes.
B. Red-orange discoloration of body fluids.
C. Drowsiness and lethargy.
D. Decreased appetite and nausea.
Which assessment finding in a client receiving chemotherapy indicates an urgent need for intervention?
A. Dry mouth and mouth ulcers.
B. Nausea and vomiting.
C. Temperature of 100.5°F (38.1°C) or higher.
D. Fatigue and hair loss.
A nurse is caring for a client with a history of seizures. What is the most important action the nurse should take during a seizure?
A. Place a tongue depressor in the client’s mouth.
B. Hold the client’s arms and legs to prevent injury.
C. Protect the client from injury and ensure a safe environment.
D. Give the client water to prevent dehydration.
A client is diagnosed with congestive heart failure (CHF). Which of the following symptoms should the nurse prioritize when assessing for fluid overload?
A. Increased urinary output.
B. Edema and weight gain.
C. Increased appetite.
D. Dry, flushed skin.
Which action should a nurse take to prevent pressure ulcers in a bedridden client?
A. Turn the client every 4 hours.
B. Encourage the client to stay in one position as long as possible.
C. Reposition the client at least every 2 hours.
D. Massage the bony prominences frequently.
A client with a new diagnosis of type 1 diabetes asks how to recognize the symptoms of hypoglycemia. Which response is most appropriate?
A. “Hypoglycemia causes confusion and thirst.”
B. “You should expect headaches and dizziness with hypoglycemia.”
C. “Shakiness, sweating, and irritability are signs of hypoglycemia.”
D. “Hypoglycemia usually results in drowsiness and weight loss.”
A nurse is caring for a client with advanced liver disease. Which lab result should the nurse expect to be elevated?
A. Hemoglobin.
B. Serum albumin.
C. Liver enzymes (AST, ALT).
D. Serum creatinine.
Which assessment finding indicates a possible complication in a client receiving warfarin therapy?
A. Pink urine.
B. Increased appetite and thirst.
C. Bruising or petechiae.
D. Mild headache.
A client reports feeling lightheaded and faint after taking their antihypertensive medication. What is the nurse’s first action?
A. Inform the client to take the medication with food.
B. Suggest that the client sit or lie down immediately.
C. Encourage the client to drink fluids to prevent dehydration.
D. Reassure the client that it is normal and will pass.
A client who has had a stroke is now presenting with slurred speech and difficulty swallowing. What is the most important action for the nurse to take?
A. Recommend a speech therapist immediately.
B. Assess the client’s ability to swallow before offering food or fluids.
C. Encourage the client to chew gum to exercise their mouth muscles.
D. Wait for the client to express their needs before taking action.
What is the priority intervention for a client experiencing an anaphylactic reaction?
A. Administer an antihistamine.
B. Provide oxygen and secure the airway.
C. Start an IV and infuse fluids.
D. Position the client in a supine position.
A nurse is preparing to administer IV potassium. Which precaution should the nurse take?
A. Administer the IV potassium as a rapid bolus to prevent hypokalemia.
B. Ensure the IV potassium is diluted and infused slowly.
C. Push the potassium directly into the vein for immediate action.
D. Administer potassium only when the client is in a seated position.
Which statement by a client diagnosed with end-stage renal disease (ESRD) indicates the need for further teaching?
A. “I need to limit my intake of sodium and potassium.”
B. “I should take my prescribed medications as directed.”
C. “I can eat a diet rich in protein without any restrictions.”
D. “I need to monitor my weight daily and report any sudden changes.”
A nurse is caring for a client on mechanical ventilation. Which of the following should the nurse monitor closely?
A. Oxygen saturation and lung sounds.
B. Electrolyte levels and temperature.
C. Client’s ability to communicate.
D. Hair and skin moisture.
A client has been diagnosed with osteoarthritis. Which instruction should the nurse provide for joint pain management?
A. “Apply ice to the joint for 30 minutes at a time.”
B. “Take pain medications only when the pain becomes severe.”
C. “Engage in moderate exercise to maintain joint function.”
D. “Avoid all physical activity to prevent further damage.”
A client is being discharged after treatment for deep vein thrombosis (DVT). Which statement indicates the client understands discharge instructions?
A. “I should keep my legs elevated while sitting.”
B. “I will avoid wearing compression stockings to prevent swelling.”
C. “I can return to strenuous exercise immediately.”
D. “I should take an over-the-counter medication for pain as needed.”
A nurse is caring for a client with a newly inserted central line. Which action should the nurse take to prevent complications?
A. Use a single-use dressing for the line.
B. Place the client in a supine position for dressing changes.
C. Ensure proper hand hygiene and use sterile technique.
D. Apply an antibiotic ointment to the insertion site daily.
A client with schizophrenia is experiencing hallucinations. Which is the best approach for the nurse to take?
A. Tell the client that the hallucinations are not real.
B. Engage the client in a conversation about the hallucinations.
C. Distract the client with activities and avoid discussing hallucinations.
D. Reassure the client that they are safe and avoid reinforcing the hallucinations.
A client with liver cirrhosis is at risk for developing which complication?
A. Hyperglycemia.
B. Bleeding due to impaired clotting.
C. Tachycardia.
D. Dehydration.
Which finding in a client with a peripherally inserted central catheter (PICC) should be reported immediately?
A. Mild swelling at the insertion site.
B. Redness and warmth at the insertion site.
C. Client reports a metallic taste in the mouth.
D. An unusual sound during the infusion of fluids.
A nurse is caring for a client post-thyroidectomy. Which complication should the nurse monitor for?
A. Hyperglycemia.
B. Hypocalcemia.
C. Pneumonia.
D. Hepatitis.
Which statement made by a client with newly diagnosed heart failure indicates the need for further teaching?
A. “I need to weigh myself at the same time every day.”
B. “I can eat as much low-sodium canned soup as I like.”
C. “I should limit my intake of salt and processed foods.”
D. “I will call my doctor if my weight increases by 2-3 pounds in a day.”
Which of the following is a sign of an impending myocardial infarction (MI)?
A. Sudden sharp, localized pain in the chest.
B. Severe, crushing chest pain that radiates to the left arm.
C. Pain that subsides with rest.
D. Dull, achy pain that persists throughout the day.
A nurse is assessing a client for potential dehydration. Which finding is most indicative of dehydration?
A. Increased urine output.
B. Moist mucous membranes.
C. Sunken eyes and dry skin.
D. Increased appetite.
What is the most appropriate nursing intervention for a client with a history of frequent urinary tract infections (UTIs)?
A. Limit fluid intake to prevent bladder distention.
B. Instruct the client to urinate before and after sexual intercourse.
C. Recommend the use of a catheter for frequent urination.
D. Encourage the client to hold urine as long as possible to avoid urgency.
A nurse is caring for a client with a history of peptic ulcer disease (PUD). Which symptom would indicate a complication?
A. Abdominal cramping and bloating.
B. Dark, tarry stools.
C. Occasional heartburn.
D. A decrease in appetite.
Which client statement indicates the need for further teaching regarding blood pressure management?
A. “I should avoid smoking to help lower my blood pressure.”
B. “I need to exercise for at least 30 minutes a day, five times a week.”
C. “Taking my medication only when my blood pressure is high is okay.”
D. “I should monitor my blood pressure at home regularly.”
A nurse is caring for a client diagnosed with diabetes insipidus. Which of the following is a priority intervention?
A. Restrict fluid intake.
B. Monitor urine output and specific gravity.
C. Assess for signs of hyperglycemia.
D. Encourage high sodium intake.
A client presents with sudden onset of severe headaches and a stiff neck. What condition should the nurse suspect?
A. Migraine.
B. Tension headache.
C. Meningitis.
D. Sinusitis.
A client receiving IV fluids reports a sudden, sharp chest pain. What is the nurse’s priority action?
A. Administer pain medication.
B. Stop the IV infusion and notify the physician.
C. Change the IV site.
D. Ask the client to breathe deeply.
.
Which of the following is most important for a nurse to assess in a client with a new diagnosis of pancreatitis?
A. Skin color and temperature.
B. Respiratory rate and pattern.
C. Abdominal pain and nausea.
D. Electrolyte levels and urine output.
What is a common side effect of ACE inhibitors that the nurse should educate the client about?
A. Increased risk of bleeding.
B. Persistent dry cough.
C. Constipation and bloating.
D. Diarrhea.
Which action should a nurse take to reduce the risk of catheter-associated urinary tract infections (CAUTIs)?
A. Reinsert the catheter every 2 days.
B. Keep the catheter drainage bag above the level of the bladder.
C. Ensure the catheter is secured and prevent tension on the tubing.
D. Use sterile technique when emptying the drainage bag.
A client with a history of heart failure is now presenting with increased dyspnea, orthopnea, and peripheral edema. What is the nurse’s priority action?
A. Encourage the client to lie flat to promote lung expansion.
B. Increase the client’s fluid intake to prevent dehydration.
C. Notify the healthcare provider and monitor the client’s vital signs.
D. Assist the client with ambulation to reduce swelling.
What is the priority action for a nurse caring for a client with a suspected spinal cord injury?
A. Administer pain medication.
B. Immobilize the client and maintain cervical alignment.
C. Begin range-of-motion exercises.
D. Monitor for respiratory changes.
A client has been prescribed a new medication for anxiety. Which statement should be included in the nurse’s teaching plan?
A. “It is safe to drive as soon as you start the medication.”
B. “The medication may take a few weeks to show its full effect.”
C. “You should avoid any type of exercise while on this medication.”
D. “Take the medication only when you feel anxious.”
A nurse is caring for a client who has just been admitted with acute pancreatitis. What is a priority action for the nurse?
A. Start a clear liquid diet.
B. Administer prescribed pain relief medication.
C. Monitor blood glucose levels.
D. Encourage the client to take deep breaths.
A client is diagnosed with deep vein thrombosis (DVT) and is on anticoagulant therapy. Which instruction should the nurse provide?
A. “Avoid eating green leafy vegetables.”
B. “It is safe to take aspirin for headaches.”
C. “Report any unusual bruising or bleeding immediately.”
D. “You can stop the medication if you feel well.”
What is an appropriate intervention for a client receiving continuous enteral feedings to reduce the risk of aspiration?
A. Maintain the client in a supine position during feeding.
B. Administer feedings at room temperature.
C. Keep the head of the bed elevated at least 30-45 degrees.
D. Flush the feeding tube with water only once per shift.
A client with a spinal cord injury at T6 reports a sudden, severe headache, and elevated blood pressure. What condition should the nurse suspect?
A. Autonomic dysreflexia.
B. Orthostatic hypotension.
C. Spinal shock.
D. Hemorrhagic stroke.
A nurse is caring for a client who has been receiving chemotherapy. Which finding should the nurse report immediately?
A. Mouth sores and loss of appetite.
A nurse is caring for a client with an arterial ulcer. Which characteristic should the nurse expect to observe?
A. Shallow, irregular wound edges with yellow slough.
B. A deep, red wound with heavy exudate.
C. Smooth, even wound edges with minimal exudate.
D. Pale wound base, with a well-defined edge.
A nurse is providing discharge instructions for a client recovering from a mastectomy. Which statement indicates the client needs more teaching?
A. “I will avoid lifting heavy objects with my affected arm.”
B. “I should perform arm exercises to improve circulation.”
C. “I can start using lotion on my surgical site as soon as I feel comfortable.”
D. “I should wear a compression sleeve on my arm to prevent lymphedema.”
What is the priority action for a nurse to take when caring for a client with a newly inserted nasogastric (NG) tube?
A. Offer the client clear fluids immediately.
B. Confirm tube placement by checking pH of aspirate.
C. Tape the tube to the client’s cheek.
D. Remove the tube if the client complains of discomfort.
A client is being treated for dehydration. Which observation indicates that the treatment is effective?
A. Increased heart rate.
B. Decreased blood pressure.
C. Increased urine output and improved skin turgor.
D. Increased thirst.
A nurse is monitoring a client for signs of fluid overload. Which of the following should be a primary concern?
A. Weight loss.
B. Increased urinary output.
C. Shortness of breath and crackles in the lungs.
D. Decreased appetite.
Which condition is characterized by inflammation and irritation of the gastric lining?
A. Peptic ulcer disease.
B. Gastritis.
C. Cholecystitis.
D. Pancreatitis.
A nurse is caring for a client after a stroke. Which action is a priority to promote safety?
A. Place the client in a high Fowler’s position.
B. Use restraints to prevent the client from falling.
C. Ensure the client’s call light is within reach.
D. Place the client on a low bed with side rails up.
A client with heart failure is prescribed a diuretic. What should the nurse monitor to detect potential complications?
A. Blood pressure and respiratory rate.
B. Serum potassium levels.
C. Blood sugar levels.
D. Capillary refill time.
A nurse is teaching a client with chronic kidney disease about dietary changes. Which food should the client be instructed to avoid?
A. Fresh fruits.
B. Whole grains.
C. Processed meats.
D. Low-fat dairy products.
A client has been diagnosed with a pressure ulcer stage II. What is the characteristic feature of this type of ulcer?
A. Full-thickness skin loss involving muscle or bone.
B. Partial-thickness skin loss involving the epidermis and/or dermis.
C. A shallow wound with slough or eschar.
D. Intact skin with non-blanchable redness.
What should a nurse include in the care plan for a client post-laparotomy?
A. Keep the incision site moist to promote healing.
B. Encourage deep breathing and coughing exercises.
C. Allow the client to eat a heavy meal shortly after surgery.
D. Limit the client’s fluid intake to reduce swelling.
Which is a primary nursing concern when caring for a client with a nasogastric (NG) tube for feeding?
A. Ensuring the client is positioned supine.
B. Checking for proper tube placement before each feed.
C. Encouraging the client to speak frequently.
D. Monitoring the client’s blood pressure every 4 hours.
A client with chronic obstructive pulmonary disease (COPD) is being discharged. Which instruction is most important for the nurse to include?
A. “Increase your intake of high-sodium foods.”
B. “Limit fluids to prevent bloating.”
C. “Avoid exposure to respiratory irritants and infections.”
D. “Exercise only when you feel short of breath.”
A nurse is assessing a client for dehydration. Which of the following findings is most concerning?
A. Moist skin and warm temperature.
B. Oliguria and dry mucous membranes.
C. Clear urine and decreased blood pressure.
D. Increased appetite and weight gain.
What should a nurse do if a client on anticoagulant therapy reports sudden severe back pain?
A. Continue monitoring without further action.
B. Administer prescribed pain medication and monitor for other symptoms.
C. Notify the physician and assess for signs of internal bleeding.
D. Encourage the client to lie down and rest.
Which of the following indicates a nurse is effectively educating a client about hypertension management?
A. “I can stop taking my blood pressure medication when I feel better.”
B. “I will monitor my blood pressure at home regularly.”
C. “I should consume more salt to help my blood pressure.”
D. “Physical activity is not recommended for my condition.”
A client with heart failure is experiencing orthopnea. Which intervention is most appropriate?
A. Position the client flat to aid in relaxation.
B. Place the client in a high-Fowler’s position to facilitate breathing.
C. Administer supplemental oxygen only if needed.
D. Encourage the client to lie on their back for a short rest.
What is the best approach for a nurse to take when administering oral medications to an elderly client with difficulty swallowing?
A. Crush the medication and mix it with a large amount of water.
B. Mix the medication with a small amount of food or drink unless contraindicated.
C. Skip the medication if the client cannot swallow whole tablets.
D. Administer the medication using a feeding tube without consulting the physician.
A client is admitted with a diagnosis of appendicitis. Which finding is a priority for the nurse to report?
A. Mild, intermittent abdominal pain.
B. Tenderness in the right lower quadrant (RLQ).
C. Sudden, sharp increase in abdominal pain and fever.
D. Decreased appetite and mild nausea.
A nurse is assessing a client who has been on long-term corticosteroid therapy. Which symptom should prompt further investigation?
A. Weight gain and increased appetite.
B. Insomnia and nervousness.
C. Increased swelling in the lower extremities.
D. Persistent, non-productive cough.
Which of the following is the most appropriate nursing intervention for a client with a suspected deep vein thrombosis (DVT)?
A. Apply a heat pack to the affected leg.
B. Elevate the affected leg above heart level.
C. Encourage ambulation to prevent further clotting.
D. Massage the leg to improve circulation.
What is the nurse’s priority when caring for a client receiving chemotherapy who is at risk for infection?
A. Administer prescribed antibiotics promptly.
B. Provide the client with a high-protein diet.
C. Ensure the client receives frequent rest periods.
D. Practice strict hand hygiene and monitor for signs of infection.
A client receiving warfarin therapy asks how long they need to stay on the medication. What should the nurse’s response be?
A. “You will need to take this medication for the rest of your life.”
B. “Your doctor will decide how long you should take it based on your condition.”
C. “You can stop taking it as soon as your symptoms improve.”
D. “This medication is only for a few weeks, and you will be fine soon.”
A client is diagnosed with a stroke and has difficulty moving their right arm and leg. What should the nurse include in the care plan?
A. Encourage the client to lie on their left side.
B. Ensure the client’s safety with assistive devices and frequent positioning.
C. Limit range-of-motion exercises to avoid pain.
D. Keep the client in a prone position for prolonged periods.
A nurse is caring for a client with congestive heart failure (CHF). Which finding indicates the need for immediate intervention?
A. Weight gain of 1-2 pounds over 2 days.
B. A decrease in appetite and fatigue.
C. Severe dyspnea at rest and cyanosis.
D. Generalized edema of the extremities.
A nurse should monitor for signs of hypoglycemia in a client taking insulin when:
A. The client skips a meal or eats late.
B. The client exercises more than usual without altering insulin.
C. The client maintains a high-carb diet consistently.
D. The client only takes the medication at night.
Which precaution should a nurse follow when caring for a client with a known methicillin-resistant Staphylococcus aureus (MRSA) infection?
A. Wear a standard mask and gloves only.
B. Place the client in a room with negative pressure ventilation.
C. Use contact precautions, including gloves and gown.
D. Limit the client’s visitors to immediate family members only.
Which of the following is a priority action for a nurse when caring for a client with a history of seizures?
A. Restrict fluids to prevent water retention.
B. Keep the client’s bed in a high position to avoid falls.
C. Place a padded tongue blade in the client’s mouth during a seizure.
D. Ensure the client’s environment is free from hazards and easy to navigate.
A client is diagnosed with a urinary tract infection (UTI). Which teaching point should the nurse include?
A. “Avoid drinking any fluids for the next 24 hours.”
B. “Take antibiotics until you feel better, even if you miss a dose.”
C. “Drink plenty of fluids, particularly water, to flush out the bacteria.”
D. “Use a heating pad to reduce the pain in your lower back only.”
When educating a client on how to manage rheumatoid arthritis (RA), which statement is appropriate?
A. “Avoid physical activity to prevent joint strain.”
B. “Engage in regular, low-impact exercise to maintain joint function.”
C. “Stop taking anti-inflammatory medications when the pain subsides.”
D. “You can take hot showers but avoid using any assistive devices.”
What should the nurse include in a discharge plan for a client post-surgery who has a new ileostomy?
A. “You should avoid any fluids for the first week after surgery.”
B. “Keep the ileostomy site clean and dry, and empty the pouch regularly.”
C. “Replace the stoma pouch only when it becomes fully saturated.”
D. “It’s safe to perform activities such as heavy lifting right after surgery.”
A nurse is assessing a client with chronic venous insufficiency. Which symptom would the nurse expect to find?
A. Shiny, smooth skin with no hair.
B. Swelling, pigmentation changes, and varicosities.
C. Deep ulcers on the toes with pale, dry skin.
D. Pain that worsens with rest and improves with elevation.
A client is receiving a blood transfusion. Which sign should the nurse report immediately as a possible transfusion reaction?
A. Mild fever and chills.
B. Red, itchy rash and slight swelling.
C. Difficulty breathing and chest pain.
D. Headache and nausea.
A nurse is caring for a client with diabetes who is experiencing hypoglycemia. Which intervention should the nurse implement first?
A. Administer insulin as ordered.
B. Offer the client a glass of orange juice.
C. Provide the client with a high-protein snack.
D. Monitor the client’s blood glucose every 30 minutes.
Which condition should the nurse consider for a client with a sudden decrease in urine output and high blood pressure?
A. Diabetic nephropathy.
B. Acute glomerulonephritis.
C. Chronic kidney disease.
D. Urinary tract infection (UTI).
A nurse is caring for a client with a history of seizures. Which of the following should be included in the nurse’s plan of care?
A. Place a tongue blade in the client’s mouth to prevent biting.
B. Clear the area of hard objects and put the bed in the lowest position.
C. Restrict fluids to prevent water retention.
D. Place the client in a prone position during a seizure.
A client with chronic obstructive pulmonary disease (COPD) is prescribed a bronchodilator. When should the nurse instruct the client to use this medication?
A. Immediately before meals to aid digestion.
B. Only when shortness of breath is severe.
C. Prior to activities that may cause shortness of breath.
D. Only at bedtime to promote sleep.
Which of the following is a primary risk for a client with a history of deep vein thrombosis (DVT)?
A. Increased risk of hypertension.
B. Risk of pulmonary embolism.
C. Risk of chronic kidney disease.
D. Increased risk of diabetes.
What should the nurse teach a client who is taking a thiazide diuretic?
A. Limit intake of high-potassium foods.
B. Report any symptoms of muscle cramping or weakness.
C. Increase fluid intake to promote dehydration.
D. Avoid taking the medication with food.
A nurse is assessing a client who has been newly diagnosed with hypertension. Which finding is most concerning?
A. Blood pressure reading of 140/90 mmHg.
B. Blood pressure reading of 160/110 mmHg.
C. A history of occasional headaches.
D. Mild dizziness upon standing.
A nurse is caring for a client with Parkinson’s disease. Which of the following is most important for the nurse to include in the care plan?
A. Encourage the client to rest frequently to prevent fatigue.
B. Monitor the client for signs of aspiration and implement swallowing precautions.
C. Ensure the client uses a low-fat, low-sodium diet.
D. Allow the client to ambulate without assistance to promote independence.
Which of the following is an appropriate nursing action for a client with a new colostomy?
A. Teach the client to irrigate the stoma every day.
B. Encourage the client to limit fluid intake to prevent diarrhea.
C. Keep the stoma site clean and dry and inspect it for any abnormalities.
D. Suggest the client avoid any form of physical activity.
A client is admitted for treatment of dehydration. Which assessment finding indicates worsening dehydration?
A. Clear, yellow urine output.
B. Increased skin turgor and moist mucous membranes.
C. Dry mouth and decreased urine output.
D. Increased appetite and weight gain.
A nurse is caring for a client post-surgery who is receiving opioid pain medication. What is a priority assessment?
A. Frequency of the client’s bowel movements.
B. Respiratory rate and level of consciousness.
C. Amount of surgical drainage.
D. Appetite and fluid intake.
A nurse is preparing a client for discharge after a stroke. Which instruction should the nurse include?
A. “You can drive as soon as you feel better.”
B. “Avoid engaging in any form of physical activity for at least a month.”
C. “Monitor your blood pressure regularly and report any significant changes.”
D. “You will no longer need medication for blood pressure control.”
Which dietary change should a nurse recommend for a client with gout?
A. Increase intake of red meat.
B. Limit intake of foods high in purines, such as seafood.
C. Avoid all vegetables to prevent flare-ups.
D. Increase dairy products to promote uric acid elimination.
A client is diagnosed with a urinary tract infection (UTI). What is the most appropriate nursing intervention?
A. Encourage the client to hold urine until they are near a restroom.
B. Instruct the client to use a heating pad over the pelvic area for pain relief.
C. Advise the client to drink plenty of fluids and take prescribed antibiotics.
D. Suggest the client avoid water and stick to caffeinated beverages.
A nurse is monitoring a client with heart failure who has recently started taking a new medication. Which side effect should be reported immediately?
A. Mild headache.
B. Occasional dizziness.
C. Sudden weight gain of 3 pounds in 1 day.
D. Increase in energy level.
What is the most appropriate action for a nurse to take when a client is in the early stage of hypothermia?
A. Encourage vigorous exercise to raise body temperature.
B. Provide the client with warm blankets and warm fluids orally.
C. Move the client into a warm bath immediately.
D. Keep the client in a cool room to avoid overheating.
A nurse is caring for a client with COPD who has an oxygen saturation of 88%. What should the nurse do first?
A. Increase the client’s oxygen flow rate.
B. Ask the client to breathe rapidly to increase oxygen levels.
C. Place the client in a high-Fowler’s position.
D. Encourage the client to take slow, deep breaths.
A nurse is preparing to administer a medication that should be taken on an empty stomach. What is the most appropriate timing for this medication?
A. 30 minutes after breakfast.
B. 1 hour before meals.
C. Right after lunch.
D. With the evening meal.
A nurse is caring for a client post-myocardial infarction (MI). Which of the following findings is most concerning?
A. Mild pain at the surgical site.
B. Sudden onset of shortness of breath and crackles.
C. Bruising at the site of a cardiac catheterization.
D. Slight increase in temperature.
A client with type 2 diabetes is being discharged. Which statement by the client indicates the need for further teaching?
A. “I will take my blood glucose before meals and at bedtime.”
B. “I need to limit my intake of sugary foods and drinks.”
C. “I can skip my medication if I am not feeling well.”
D. “I will wear comfortable shoes to prevent foot injuries.”
Which of the following is a priority assessment for a client who has been admitted for an exacerbation of asthma?
A. Heart rate and rhythm.
B. Respiratory rate and lung sounds.
C. Level of consciousness.
D. Bowel movements and fluid intake.
A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which assessment is most important before starting dialysis?
A. Assessing for signs of hyperkalemia.
B. Checking the weight gain over the last 24 hours.
C. Monitoring blood pressure and heart rate.
D. Measuring urine output for the last 12 hours.
A nurse is teaching a client with tuberculosis (TB) about the disease. Which statement by the client indicates an understanding of the teaching?
A. “I should only take my medication when I feel sick.”
B. “I can stop taking the medication once I feel better.”
C. “It’s important to take the full course of my antibiotics as prescribed.”
D. “I can return to work as soon as I start feeling better.”
A client with a history of pancreatitis reports sudden severe abdominal pain and vomiting. What should the nurse do first?
A. Offer the client fluids to drink.
B. Assess for signs of shock and notify the healthcare provider.
C. Place the client on a low-fat diet.
D. Encourage the client to lie flat in bed.
A nurse is assessing a newborn and finds a bulging fontanelle, irritability, and a high-pitched cry. What is the most likely condition?
A. Dehydration.
B. Hydrocephalus.
C. Jaundice.
D. Cephalohematoma.
What is the most effective way to prevent a client from developing a deep vein thrombosis (DVT) after surgery?
A. Keep the client in bed with the legs elevated.
B. Administer anticoagulant therapy as prescribed.
C. Ensure the client is not moving for the first 24 hours.
D. Restrict fluid intake to prevent fluid overload.
A nurse is caring for a client with chronic pain. Which of the following would be the most appropriate approach to pain management?
A. Rely solely on opioid medications for pain relief.
B. Combine pharmacological and non-pharmacological methods.
C. Use only non-pharmacological methods.
D. Monitor for side effects of medications but do not offer alternatives.
A client is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following findings would be the most concerning?
A. Use of accessory muscles to breathe.
B. Wheezing on auscultation.
C. Increased respiratory rate with cyanosis.
D. Low-grade fever and malaise.
A client with heart failure has a weight gain of 2 kg (4.4 lbs) over 2 days. What should the nurse do next?
A. Administer diuretics as prescribed.
B. Encourage the client to increase fluid intake.
C. Monitor the client’s fluid intake and output for the next 24 hours.
D. Report the weight gain to the physician immediately.
Which of the following is the best practice for the nurse when administering medication through a percutaneous endoscopic gastrostomy (PEG) tube?
A. Crush tablets and mix them with a large amount of water.
B. Mix medications together before administering.
C. Administer each medication separately and flush the tube between medications.
D. Administer liquid medications only, without flushing.
What is the priority assessment for a client who has just been admitted after a motor vehicle accident with multiple injuries?
A. Assessment of peripheral pulses.
B. Evaluation of the Glasgow Coma Scale score.
C. Checking for skin lacerations and abrasions.
D. Monitoring for signs of deep vein thrombosis (DVT).
A nurse is caring for a client with pancreatitis. Which intervention should the nurse implement first?
A. Administer prescribed analgesics.
B. Provide a clear liquid diet.
C. Withhold oral food and fluids until inflammation decreases.
D. Encourage high-protein, high-fat meals.
Which of the following should a nurse include in the teaching plan for a client with newly diagnosed hypertension?
A. “Eat a diet high in saturated fats to maintain energy.”
B. “Exercise regularly, aiming for at least 30 minutes per day.”
C. “Limit your fluid intake to prevent swelling.”
D. “Avoid all sources of salt, including natural sources.”
A nurse is preparing to administer a potassium supplement to a client with hypokalemia. Which of the following findings should the nurse report to the healthcare provider before administering the medication?
A. A serum potassium level of 3.5 mEq/L.
B. A heart rate of 110 bpm.
C. A serum potassium level of 2.9 mEq/L.
D. A slight increase in respiratory rate.
A client is receiving a blood transfusion and suddenly reports chills, fever, and back pain. What should the nurse do first?
A. Increase the rate of the blood transfusion.
B. Administer an antipyretic medication.
C. Stop the transfusion and notify the healthcare provider.
D. Apply a warm compress to the client’s back.
A nurse is caring for a client post-surgery who is at risk for developing deep vein thrombosis (DVT). Which intervention is most appropriate?
A. Encourage the client to remain on bed rest.
B. Administer prescribed anticoagulant medications.
C. Apply a warm compress to the client’s legs.
D. Elevate the client’s legs only when sitting.
A client with a history of peptic ulcer disease is admitted with hematemesis. What should the nurse do first?
A. Assist the client to a sitting position.
B. Administer IV fluids as ordered.
C. Check the client’s vital signs and monitor for shock.
D. Offer the client water to dilute the blood.
Which of the following is a common complication of immobility that should be included in patient teaching?
A. Increased appetite and weight gain.
B. Deep vein thrombosis (DVT) and pressure ulcers.
C. Improved circulation and muscle tone.
D. Increased range of motion.
A nurse is caring for a client with a history of seizures. Which of the following is an appropriate safety measure?
A. Restrict the client’s movement to prevent injury.
B. Ensure the client has a padded side rail and suction equipment at the bedside.
C. Place the client in a high-Fowler’s position at all times.
D. Keep the lights dim in the client’s room to reduce stimulation.
What should a nurse instruct a client to do before undergoing a colonoscopy?
A. Increase fiber intake 24 hours before the procedure.
B. Drink a clear liquid diet and take a prescribed bowel preparation.
C. Eat a regular diet and drink a large glass of water.
D. Avoid any medication for 48 hours prior.
A client with chronic pain asks for non-pharmacological methods to help manage their pain. Which of the following should the nurse suggest?
A. Increase the dose of pain medication.
B. Use relaxation techniques, such as deep breathing and guided imagery.
C. Avoid physical activity to reduce pain.
D. Limit interaction with family and friends.
A nurse is caring for a client who has just received a dose of lorazepam for anxiety. Which assessment is the priority?
A. Assessing the client’s blood pressure.
B. Monitoring the client’s respiratory rate.
C. Checking the client’s pain level.
D. Measuring the client’s temperature.
A client has been diagnosed with hypothyroidism. Which of the following symptoms should the nurse expect to observe?
A. Weight loss and excessive sweating.
B. Rapid heart rate and increased energy.
C. Fatigue, weight gain, and dry skin.
D. Insomnia and increased appetite.
Which of the following is an early sign of hypoglycemia in a diabetic client?
A. Excessive thirst and frequent urination.
B. Sweating, shakiness, and confusion.
C. Nausea and vomiting.
D. Slow, deep respirations.
A client is admitted with a suspected myocardial infarction (MI). Which diagnostic test should the nurse anticipate being ordered first?
A. Chest X-ray.
B. Electrocardiogram (ECG).
C. Complete blood count (CBC).
D. Echocardiogram.
A nurse is caring for a client with a gastric ulcer. Which of the following foods should the nurse recommend avoiding?
A. Bananas and apples.
B. Spicy foods and caffeine.
C. Lean meats and vegetables.
D. Low-fat yogurt and rice.
A nurse is evaluating a client’s understanding of their medication for heart failure. Which statement indicates a need for further teaching?
A. “I will weigh myself every morning and report any weight gain of 2 pounds or more in a day.”
B. “I can stop my medication if I start to feel better.”
C. “I need to take my medication at the same time each day.”
D. “I should avoid eating foods high in sodium.”
A client with cirrhosis is exhibiting signs of confusion and agitation. What is the most likely cause?
A. Hyperkalemia.
B. Hepatic encephalopathy.
C. Dehydration.
D. Diabetes.
Here are some essay questions along with comprehensive sample answers relevant to nursing, healthcare, and patient care:
1. Discuss the role of patient education in preventing hospital readmissions for chronic illnesses.
Sample Answer: Patient education plays a critical role in preventing hospital readmissions, especially for individuals with chronic illnesses such as heart failure, diabetes, or chronic obstructive pulmonary disease (COPD). Effective education empowers patients to manage their conditions more independently and reduces the likelihood of complications that can lead to re-hospitalization.
Education should encompass multiple dimensions, including the importance of medication adherence, recognizing early signs of worsening symptoms, dietary restrictions, and lifestyle modifications such as increased physical activity and smoking cessation. According to the American Heart Association (AHA) and the World Health Organization (WHO), well-informed patients are more likely to engage in self-care behaviors, which can decrease the risk of readmissions.
An evidence-based approach to patient education includes the use of teach-back methods, where the patient repeats the instructions to confirm understanding, and interactive technology, such as mobile health applications, which can provide reminders and track patient progress. Additionally, empowering patients to take an active role in their treatment through collaborative care models has been shown to improve outcomes.
In practice, nurses and healthcare providers should ensure that educational materials are culturally appropriate and tailored to the patient’s literacy level. Studies have demonstrated that patients with lower health literacy may require more personalized teaching methods to comprehend their health condition and treatment plan.
Overall, patient education not only promotes better health outcomes but also supports healthcare systems by reducing costs associated with preventable readmissions. A comprehensive strategy that includes patient education as a core component will ultimately lead to more sustainable and effective management of chronic illnesses.
2. Analyze the significance of interdisciplinary collaboration in improving patient care outcomes.
Answer: Interdisciplinary collaboration, which involves professionals from different healthcare fields working together, has been shown to improve patient care outcomes significantly. The healthcare system today requires a holistic approach to treat complex cases, especially in acute and chronic conditions. Collaboration among physicians, nurses, pharmacists, therapists, social workers, and other specialists ensures comprehensive care that addresses all aspects of a patient’s needs.
Research by the Institute of Medicine (IOM) emphasizes that collaborative teamwork can enhance communication, reduce redundancies, improve treatment efficiency, and boost patient satisfaction. For example, in managing a patient with heart failure, a team approach involving cardiologists, nurses, dietitians, and pharmacists can ensure that patients receive appropriate medication, lifestyle counseling, and support to prevent hospital readmissions.
The benefits of interdisciplinary collaboration extend beyond patient care to include staff satisfaction and professional development. Working in a collaborative environment fosters mutual respect and trust among healthcare workers, leading to increased job satisfaction and lower burnout rates. This, in turn, contributes to better patient care and reduces turnover within healthcare institutions.
To implement effective interdisciplinary collaboration, healthcare organizations should prioritize ongoing training, encourage open communication, and create systems that facilitate teamwork, such as shared electronic health records (EHRs). Additionally, the development of care protocols and regular team meetings can help ensure all members are aligned with treatment goals.
3. Explain the importance of cultural competence in nursing practice.
Answer
Cultural competence in nursing is crucial for delivering high-quality care that respects and acknowledges the diverse backgrounds of patients. It involves understanding and integrating the cultural beliefs, values, and practices of patients into the planning and implementation of their care. Nurses with cultural competence can bridge communication gaps and foster trust with patients from various cultural and ethnic backgrounds, thereby improving the overall patient experience and health outcomes.
One of the primary aspects of cultural competence is effective communication. For instance, language barriers can be overcome with the use of interpreters or translation services, ensuring patients fully understand their treatment plan. It is also essential for nurses to be aware of cultural practices that may influence a patient’s health beliefs and behaviors, such as dietary restrictions or the role of family in decision-making.
Cultural competence leads to more personalized care, which has been associated with higher patient satisfaction and compliance. Studies have shown that culturally competent care can reduce health disparities, which disproportionately affect minority groups. For example, patients who feel respected and understood are more likely to seek follow-up care and adhere to treatment protocols, ultimately leading to better health outcomes.
Healthcare education should include cultural competence training to prepare future nurses for the challenges they will face in diverse clinical settings. Additionally, healthcare facilities should encourage continuous learning and reflection on cultural biases to ensure staff members remain sensitive to the evolving needs of their patient populations.
These practices contribute to building a more inclusive healthcare environment that promotes equity, understanding, and respect.
4. Evaluate the impact of technology on patient care and nursing practice.
Answer: The integration of technology into patient care has significantly transformed nursing practice, offering improved outcomes and enhanced patient safety. Technology, such as electronic health records (EHRs), telehealth services, and patient monitoring systems, has revolutionized how nurses manage and communicate patient information.
EHRs facilitate better data organization and information sharing among healthcare providers. This ensures that patient information is easily accessible, reducing errors associated with manual record-keeping. For instance, a nurse can quickly access a patient’s history, lab results, and medications, leading to more informed decision-making. The use of EHRs has been linked to a decrease in medication errors and improved patient care coordination (Bates et al., 2014).
Telehealth, particularly during the COVID-19 pandemic, has proven to be an essential tool for maintaining continuity of care. Through virtual consultations, nurses can assess patients remotely, provide education, and manage chronic diseases effectively, reducing the need for in-person visits and minimizing exposure to infectious diseases. Studies show that telehealth has improved access to care for patients in rural and underserved areas (Darkins & Cary, 2015).
Patient monitoring systems, including wearable devices and remote sensors, offer real-time data on a patient’s vital signs, enhancing the ability to detect early warning signs of complications. This leads to timely interventions and improved patient outcomes. The application of artificial intelligence (AI) and data analytics in healthcare further aids in identifying patterns that can predict potential health issues, allowing for preventive measures (Jiang et al., 2017).
However, despite the advantages, the use of technology in nursing practice also presents challenges. Issues such as data security, patient privacy, and the potential for technology-related errors must be addressed. Ensuring that nurses are adequately trained and that systems are user-friendly is vital to maximize benefits and minimize drawbacks.
In conclusion, technology has a profound impact on patient care and nursing practice, enhancing efficiency, safety, and accessibility. Continuous education and policy development will be essential to navigate the evolving landscape of healthcare technology effectively.
5. Discuss the significance of mental health care in primary nursing practice.
Answer: Mental health care is an essential aspect of primary nursing practice, as it addresses the psychological well-being of patients, which directly impacts their overall health. Nurses often serve as the first point of contact for individuals experiencing mental health issues, making them pivotal in recognizing symptoms, providing initial support, and facilitating appropriate referrals.
Mental health disorders are prevalent, affecting millions of people globally. According to the World Health Organization (WHO), depression is one of the leading causes of disability worldwide, and anxiety disorders are common among various age groups. The stigma surrounding mental health can prevent individuals from seeking help, making the nurse’s role in promoting mental health awareness and reducing stigma crucial (Corrigan et al., 2012).
Primary nurses are uniquely positioned to observe changes in a patient’s behavior, mood, or cognitive function, which may indicate underlying mental health issues. Early intervention can prevent the progression of mental health disorders and promote better outcomes. Nurses must be equipped with the skills to conduct mental health assessments, recognize warning signs, and provide basic counseling or crisis intervention when necessary.
Nursing education should include mental health training to prepare nurses for this aspect of patient care. This includes developing communication skills that foster trust and empathy, understanding psychiatric disorders, and learning strategies to support patients experiencing mental health crises.
In addition, nurses should collaborate with mental health specialists, therapists, and social workers to create a comprehensive care plan. This collaborative approach ensures that patients receive holistic care that addresses both physical and mental health needs, leading to better recovery and a reduced risk of comorbidities.
Overall, the significance of mental health care in primary nursing practice cannot be overstated. By prioritizing mental health, nurses can contribute to the well-being of their patients and help bridge the gap between mental and physical health, promoting a more comprehensive and patient-centered approach to care.
6. Explain the challenges and strategies of managing chronic pain in elderly patients.
Answer: Managing chronic pain in elderly patients presents unique challenges due to physiological changes associated with aging, multiple comorbidities, and the potential for polypharmacy. Chronic pain can lead to a decline in quality of life, decreased mobility, and increased risk of depression and social isolation.
One of the primary challenges is the underreporting of pain by elderly patients, who may believe that pain is a normal part of aging or may be hesitant to report pain due to fear of medication dependency or side effects. Additionally, older adults often have complex medical histories and may be taking medications that interact with pain management drugs, increasing the risk of adverse effects.
Pain management in the elderly should be approached holistically, considering both pharmacological and non-pharmacological strategies. Non-pharmacological methods, such as physical therapy, acupuncture, and cognitive-behavioral therapy (CBT), can be effective in reducing pain without the risks associated with medications. For example, physical therapy can improve mobility and strengthen muscles, while CBT helps patients manage their perception of pain and cope with associated stress.
When pharmacological treatment is necessary, it is essential to use medications cautiously. Non-opioid analgesics, such as acetaminophen or NSAIDs, are often the first line of treatment. Opioids should be used sparingly and only when the benefits outweigh the risks, with close monitoring for signs of dependency, sedation, and constipation (Sullivan et al., 2010). Topical treatments and low-dose antidepressants or anticonvulsants can also be effective in managing pain related to neuropathy or musculoskeletal conditions.
Educating patients and caregivers on the importance of proper medication use, potential side effects, and the role of lifestyle modifications can empower them to play an active role in pain management. Strategies such as regular exercise, a balanced diet, and adequate sleep can contribute to better pain management and overall well-being.
In conclusion, managing chronic pain in elderly patients requires a multifaceted approach that balances medication use with non-pharmacological strategies, patient education, and careful monitoring. This approach not only addresses pain but also supports the overall health and quality of life of elderly individuals.