Question: A nurse is reviewing ABG results. Which of the following values is consistent with respiratory alkalosis?
Answer Choices:\n\npH 7.30, PaCO₂ 55 mmHg pH 7.48, PaCO₂ 30 mmHg pH 7.35, PaCO₂ 45 mmHg pH 7.28, PaCO₂ 48 mmHg
Answer:\npH 7.48, PaCO₂ 30 mmHg
Question: Which of the following findings should the nurse report immediately in a client receiving TPN (total parenteral nutrition)?
Answer Choices:\n\nBlood glucose of 150 mg/dL Temperature of 101.2°F (38.4°C) Weight gain of 1 kg over 2 days Capillary refill of less than 2 seconds
Answer:\nTemperature of 101.2°F (38.4°C)
Question: Which laboratory result is most important for the nurse to monitor in a client taking furosemide (Lasix)?
Answer Choices:\n\nSodium Hemoglobin Potassium Glucose
Answer:\nPotassium
Question: A nurse is preparing to administer 8 units of regular insulin and 12 units of NPH insulin. Which of the following steps is correct?
Answer Choices:\n\nDraw up NPH first, then regular insulin Mix both in the vial before drawing Draw up regular insulin first, then NPH insulin Use separate syringes for both insulins
Answer:\nDraw up regular insulin first, then NPH insulin
Question: A client with renal failure is on a low-protein diet. Which of the following lab values is most important to monitor?
Answer Choices:\n\nHematocrit Albumin Potassium Creatinine
Answer:\nAlbumin
Question: Which of the following ECG changes is most concerning for hyperkalemia?
Answer Choices:\n\nST depression Peaked T waves U waves Prolonged QT interval
Answer:\nPeaked T waves
Question: The nurse is caring for a client with a history of alcohol use disorder who is experiencing confusion, ataxia, and nystagmus. Which condition should the nurse suspect?
Answer Choices:\n\nHepatic encephalopathy Korsakoff syndrome Wernicke’s encephalopathy Delirium tremens
Answer:\nWernicke’s encephalopathy
Question: A client is admitted with a full-thickness burn injury. Which of the following is the priority nursing assessment?
Answer Choices:\n\nPresence of eschar Pain level Airway patency Extent of the burn
Answer:\nAirway patency
Question: A client has been newly diagnosed with Type 1 diabetes. Which of the following is most important for the nurse to include in teaching?
Answer Choices:\n\nHow to rotate injection sites. How to use a glucometer. How to administer oral hypoglycemics. How to treat diabetic neuropathy.
Answer:\nHow to use a glucometer.
Question: Which of the following is the priority teaching point for a patient newly prescribed warfarin (Coumadin)?
Answer Choices:\n\nIncrease intake of green leafy vegetables Take the medication with antacids Use an electric razor when shaving Expect blood in the urine
Answer:\nUse an electric razor when shaving
Question: A nurse is caring for a patient with a sodium level of 127 mEq/L. Which of the following symptoms would the nurse expect?
Answer Choices:\n\nHypotension, bradycardia, and dry skin Confusion, headache, and nausea Tetany, positive Chvostek’s sign Flushed skin, fever, and restlessness
Answer:\nConfusion, headache, and nausea
Question: A nurse assesses a client with cirrhosis who has a distended abdomen. Which of the following interventions is most appropriate to manage ascites?
Answer Choices:\n\nEncourage fluid intake Administer spironolactone Limit carbohydrate intake Provide high-protein meals
Answer:\nAdminister spironolactone
Question: A client with COPD is receiving oxygen therapy. Which of the following findings requires immediate action by the nurse?
Answer Choices:\n\nOxygen saturation of 91% Respiratory rate of 10 breaths/min Clubbing of the fingers Barrel chest
Answer:\nRespiratory rate of 10 breaths/min
Question: The nurse is caring for a patient who reports sudden severe headache, blurred vision, and projectile vomiting. Which of the following should be suspected?
Answer Choices:\n\nMigraine headache Ischemic stroke Increased intracranial pressure Meningitis
Answer:\nIncreased intracranial pressure
Question: Nurse W. is admitting a client that is suspected to have suicidal ideation. The best course of action for Nurse W. to take is to:
Answer Choices:\n\nPlace the client in a room at the end of the hall for close observation. Assign a roommate who has recovered from suicidal ideation. Remove personal items that could be used for self-harm. Encourage the client to journal about their feelings.
Answer:\nRemove personal items that could be used for self-harm.
Question: A nurse is caring for a client experiencing auditory hallucinations. Which of the following is the most appropriate nursing intervention?
Answer Choices:\n\nTell the client that the voices are not real. Ask the client what the voices are saying. Distract the client with music or activities. Encourage the client to rest in their room.
Answer:\nAsk the client what the voices are saying.
Question: The nurse is evaluating a client’s neurological status and finds unequal pupils and decreased level of consciousness. What is the priority action?
Answer Choices:\n\nNotify the healthcare provider immediately Reassess in 30 minutes Apply oxygen and elevate the head of bed Call the family to update them
Answer:\nNotify the healthcare provider immediately