would you like free audiobooks click the link in the description question one a 55-year-old male patient with a history of type 2 diabetes melodus presents with complaints of blurred vision and dizziness his current medications include meformin and sytin which of the following actions should the nurse take first a check the patient blood glucose level B administer a dose of sytin C provide a carbohydrate snack D assess the patient's blood pressure answer a check the patient's blood glucose level rationale in a diabetic patient presenting with symptoms of blurred vision and dizziness the first priority is to assess for hypoglycemia or hypoglycemia by checking the blood glucose level this immediate action can identify a potentially life-threatening condition that requires urgent intervention question two a nurse is caring for a postoperative patient who has just returned from surgery with a prescription for morphine sulfate for pain management the patient is currently asleep and upon assessment the nurse notes a respiratory rate of eight breaths per minute what is the nurse's best course of action a wake the patient and administer the morphine B administer noo Zone C reassess the patient respiratory rate in 15 minutes D hold the morphine and notify the physician answer D hold the morphine and notify the physician rationale a respiratory rate of eight breaths per minute indicates respiratory depression a contraindication for administering additional opioids like morphine the nurse should hold the medication and immediately notify the phys position for further instructions prioritizing the patient's respiratory status question three a patient with congestive heart failure is exhibiting signs of fluid overload which nursing intervention is most appropriate to address this condition a restrict fluid intake to 1 liter per day B encourage ambulation three times a day C administer prescribed diuretics D increase dietary sodium intake answer C administer prescribed diuretics rationale in patients with congestive heart failure and signs of fluid overload administering prescribed diuretics is the most appropriate intervention to remove excess fluid from the body relieve symptoms and prevent further complications question four a nurse is preparing to administer a blood transfusion to a patient which of the following actions is the most critical to perform before initiating the trans transfusion a verify the patient's identity with two identifiers B premedicate the patient with an antipyretic C ensure that the intervenous line is flushed with normal saline D check the patient's temperature answer a verify the patient's identity with two identifiers rationale the most critical step before initiating a blood trans Fusion is to verify the patient identity using two identifiers EG name and date of birth this action prevents transfusion errors and ensures patient safety question five a patient is admitted with severe abdominal pain and a suspected diagnosis of appendicitis which of the following nursing assessments is most important to perform initially a palpate the abdomen for tenderness B assess the patient bowel sounds C measure the patient temperature D ask about the location and onset of pain answer D ask about the location and onset of pain rationale in a patient with severe abdominal pain and suspected appendicitis the most important initial assessment is to ask about the location and onset of pain this information helps in determining the likelihood of appendicitis and guides further diagnostic testing and intervention question six a patient with chronic obstructive pulmonary disease COPD is experiencing shortness of breath the nurse has available Oxygen by a nasal canula and a nebulizer treatment prescribed what should the nurse do first a administer the nebulizer treatment B increase the oxygen flow rate C assess the patient's oxygen saturation d encourage the patient to perform p flip breathing answer C assess the patient oxygen saturation rationale the first action the nurse should take for a COPD patient experiencing shortness of breath is to assess the oxygen saturation this measurement will guide the appropriate intervention whether it's administering oxygen a nebulizer treatment or employing breathing techniques question seven a nurse is providing education to a patient with hypertension which statement by the patient indicates a need for further teaching a I should monitor my blood pressure at home regularly B I can add salt to my meals as long as I drink enough water C I will need to take my medication even if I'm feeling well D I should incorporate exercise into my daily routine answer B I can add salt to my meals as long as I drink enough water rationale this statement indicates a misunderstanding about hypertension management patients with hypertension should be advised to limit sodium intake as excessive salt can contribute to increased blood pressure levels this indicates a need for further education on dietary restrictions question 8 a nurse is caring for a patient who suddenly becomes agitated and Confused the patient heart rate is elevated and they are sweating profusely what is the nurse's priority action a administer an antis psychotic medication B perform a thorough physical assessment C restrain the patient for their safety D attempt to calm the patient by speaking in a soothing voice answer B perform a thorough physical assessment rationale the nurse's priority is to perform a thorough physical assessment to identify the underlying cause of the patient's Sudden Change in mental status and physiological signs this could indicate a range of issues from infection to adverse medication effects and guides appropriate intervention question nine a pediatric patient with a severe peanut allergy accidentally ingests a product containing penuts and starts exhibiting signs of anaphylaxis the nurse immediately administ s's epinephrine as prescribed what is the next best step a reassure the child and wait for the epinephrine to take effect B prepare to administer a second dose of epinephrine if needed C give the child an antihistamine to reduce symptoms D monitor the child's Vital Signs and oxygen saturation continuously answer D monitor the child Vital Signs and oxygen saturation continuously rationale after administering epinephrine for anaphylaxis the next best step is to continuously monitor the child's Vital Signs and oxygen saturation this monitoring is crucial to assess the child's response to the treatment and to identify any need for further intervention question 10 a patient with a history of atrial fibrillation is on warer and therapy the nurse notes the patient am R is significantly higher than the therapeutic range what is the most appropriate nursing action a administer the next dose of warin as scheduled B prepare to administer vitamin K C increase the patients intake of green leafy vegetables D obtain a repeat INR to confirm the initial results answer B prepare to administer vitamin K rationale an INR significantly higher than the therapeutic range indicates a risk of bleeding due to over anticoagulation the most appropriate action is to prepare to administer vitamin K which can help reverse the effects of warin and reduce the risk of bleeding question 11 a nurse is caring for a patient who reports nausea after undergoing chemotherapy which of the following interventions should the nurse prioritize a offer the patient a glass of water B administer prescribed antiemetic medication C encourage the patient to rest in a Supine position D provide the patient with a high-fiber meal answer B administer prescribed antiemetic medication rationale nausea is a common side effect of chemotherapy the priority nursing intervention for a patient reporting non postchemotherapy is to administer prescribed antiemetic medication to alleviate the symptom and prevent vomiting which can lead to further complications question 12 a patient is admitted with acute exacerbation of asthma the nurse notes wheezing and difficulty breathing which action should the nurse take first a administer a short acting beta Agonist by a nebulizer B perform chest phys i theapy c start oxygen therapy at 2 L per minute D encourage the patient to use P lip breathing answer a administer a short acting beta Agonist by a nebulizer rationale in an acute exacerbation of asthma the first priority is to relieve Airway constriction and improve breathing administering a short acting beta Agonist by a nebulizer is the most effective immediate intervention to achieve this question 13 a nurse is assessing a patient with suspected deep vein thrombosis DVT in the lower leg which of the following findings would be most indicative of DVT a warmth and redness over the affected area B decreased calf circumference compared to the other leg C absence of petal pulses d boldness and power of the affected leg answer a warmth and redness over the affected area rationale warmth and redness over the affected area along with swelling and pain are classic signs of deep vein thrombosis these symptoms occur due to inflammation and clot formation in the Deep veins question 14 a nurse is planning care for a patient with dehydration which of the following outcomes should be the priority a the patient will consume at least 75% of each meal B the patient skin turer will return to normal C the patient will express feelings of increased energy D the patient will have a urinary output of at least 30 milliters per hour answer D the patient will have a urinary output of at least 30 milliters hour rationale for a patient with dehydration the priority outcome is to ensure adequate hydration status which can be measured by urinary output a urinary output of at least 30 mlit per hour indicates adequate kidney function and fluid balance question 15 a nurse is caring for a patient who is post-operative day one following abdominal surgery the patient refuses to use the incentive spirometer due to pain what is the best response by the nurse a it's okay to skip it if you're in too much pain B using the incentive spirometer will prevent complications like pneumonia C I'll give you pain medication after you use the incentive spirometer D you don't have to use it if you can take deep breaths and cough effectively answer B using the incentive spirometer will prevent complications like pneumonia rationale educating the patient about the importance of using the incentive spirometer post-operatively especially to prevent pulmonary complications like pneumonia is essential this may motivate the patient to use the device despite the pain emphasizing the importance of pain management strategies to facilitate its use question 16 a nurse is preparing to teach a patient with newly diagnosed diabetes madus about managing their condition which teaching method is most effective a providing written materials only B lecturing on the importance of glucose control C demonstrating how to check blood glucose and letting the patient practice D advising the patient to join a diabetes support group answer C demonstrating how to check blood glucose and letting the patient practice rationale demonstrating how to check blood glucose and allowing the patient to practice provides hands-on experience enhancing learning and retention this method is effective in teaching self-management skills for Diabetes Care question 17 a patient with bipolar disorder is experiencing a manic episode which nursing intervention is most appropriate a engage the patient in group therapy sessions to improve social skills B provide a quiet environment and limit stimulation C encourage the patient to take on leadership roles in communal activities D increase the frequency of family visits to enhance support answer B provide a quiet environment and limit stimulation rationale during a manic episode a patient with bipolar disorder may be easily overwhelmed by external stimuli providing a quiet and minimally stimulating environment can help reduce agitation and prevent escalation of symptoms question 18 a nurse is assessing a patient who reports feeling anxious which of the following findings should the nurse recognize as a physiological manifestation of anxiety a Brady cardia B hypotension C Di f esis d decreased respiratory rate answer C diaphoresis rationale diaphoresis excessive sweating is a common physiological response to anxiety as the sympathetic nervous system is activated other manifestations might include tacac cardia hypertension and increased respiratory rate rather than the decreases mentioned in the other options question 19 a nurse is caring for a patient receiving intervenous antibiotics the patient complains of pain at the intervenous site which appears red and swollen what is the first action the nurse should take a apply a warm compress to the site B discontinue the intervenous infusion immediately C administer a prescribed analgesic D slow the rate of the infusion answer B discontinue the intervenous infusion immediately rationale pain redness and swelling at an intervenous site May indicate fitis or infiltration the first action should be to discontinue the intervenous infusion to prevent further tissue damage then assess the site further and possibly start a new intervenous line at a different site question 20 a nurse is planning care for a patient at risk for Falls which intervention is most effective in preventing Falls in a hospital setting a keeping the bed in the highest position B using restraints when the patient is alone C ensuring the patient Footwear has non-slip SS D administering sedatives regularly to prevent wandering answer C ensuring the patient Footwear has non-slip SS rationale providing non-slip Footwear is a key intervention to prevent Falls by enhancing stability and traction keeping the environment safe and promoting the use of assisted devices as needed are also important strategies question 21 a nurse is caring for a patient who has been fasting for 12 hours in preparation for a scheduled surgery the patient reports feeling light-headed and dizzy which of the following actions should the nurse take first a offer the patient a glass of water B check the patient blood glucose level C inform the surgeon about the patient symptoms D help the patient to lie down and Elevate their legs answer D help the patient to lie down and Elevate their legs rationale when a patient reports feeling light-headed and dizzy especially after fasting the first first priority is to prevent injury from potential Falls helping the patient to lie down and elevating their legs can improve cerebral profusion by promoting Venus return addressing the symptoms of orthostatic hypotension immediately question 22 a nurse is developing a plan of care for a patient with severe anxiety related to an upcoming surgery which intervention should the nurse include to help manage the patient anxiety a schedule the surgery as early in the morning as possible B limit the amount of information provided about the surgery to avoid overwhelming the patient C teach relaxation techniques and deep breathing exercises D encourage the patient to avoid discussing fears to reduce anxiety answer C teach relaxation techniques and deep breathing exercises rationale teaching relaxation techniques and deep breathing exercises is an effective intervention for managing anxiety these techniques can help the patient gain a sense of control over their anxiety by focusing on calming exercises which can be particularly beneficial in the preoperative period question 23 a patient with chronic kidney disease is undergoing hemodialysis and has a restricted fluid intake the nurse notes that the patient weight has increased by 2 kg since the last day dialysis session what is the most appropriate nursing action a encourage the patient to drink more fluids to stay hydrated B assess for signs of fluid overload and edema C adjust the dialysis machine to remove extra fluid more rapidly D instruct the patient to limit fluid intake further answer B assess for signs of fluid overload and edema rationale in a patient undergoing hemodialysis with a restricted fluid intake a weight gain of 2 kg likely indicates fluid retention the nurse should first assess for signs of fluid overload and edema to confirm fluid accumulation and then communicate these findings to the healthcare team for potential adjustments in dialysis settings question 24 a nurse is providing discharge instructions to a patient who has been prescribed warin which dietary advice is most important for the nurse to emphasize a increase intake of vitamin K rich foods like green leafy vegetables B avoid grapefruit and grapefruit juice while taking warin C maintain a consistent intake of vitamin car rich foods D eliminate all vitamin K from the diet to prevent blood clots answer C maintain a consistent intake of vitamin car Foods rationale for patients taking warin it is crucial to maintain a consistent intake of vitamin KR Foods as Vitamin K can affect the efficacy of the medication sudden changes in dietary vitamin K can lead to fluctuations in INR levels potentially causing either an increased risk of bleeding or thrombosis education about consistent dietary habits helps manage the therapeutic effects of warer and effectively question 25 a nurse is preparing to administer a subcutaneous injection to a thin elderly patient which site and technique should the nurse select to minimize the risk of injury a the dorsal Glu site using a 90° angle B the ventrogluteal site using a 45° angle C the abdominal site using a 45° angle d the deltoid site using a 90° angle answer C the abdominal site using a 45° angle rationale for thin elderly patients the abdominal site is preferred for subcutaneous injections due to the presence of adequate subcutaneous fat which can absorb the medication effectively using a 45° angle helps ensure the medication is delivered to the subcutaneous tissue minimizing the risk of muscle or nerve damage especially important in patients with decreased muscle mass visit nurs study.net for more nursing practice exams care plans and study guides