1. A nurse is caring for a patient with a history of alcohol abuse who is
at risk for delirium tremens. Which finding should the nurse report
immediately?
A. Diaphoresis
B. Tremors and anxiety
C. Hypertension and tachycardia
D. Confusion and hallucinations
Answer: D. Confusion and hallucinations
Rationale: Delirium tremens is a serious complication of alcohol
withdrawal that requires immediate treatment.
2. Which nursing action is essential when administering packed red
blood cells (PRBCs)?
A. Infuse the blood within 2 hours
B. Prime the tubing with dextrose 5%
C. Verify patient identity with another nurse
D. Monitor the patient every 30 minutes
Answer: C. Verify patient identity with another nurse
Rationale: Proper verification prevents transfusion reactions caused by
mismatched blood.
,3. A patient with chronic pain is being prescribed opioids. Which
statement indicates the need for further teaching?
A. "I should take my medication exactly as prescribed."
B. "I will take my medication with food to prevent nausea."
C. "I can stop taking the medication if I feel my pain has improved."
D. "I will monitor myself for any signs of constipation."
Answer: C. "I can stop taking the medication if I feel my pain has
improved."
Rationale: Opioid medication should be taken consistently as
prescribed. Stopping abruptly can lead to withdrawal symptoms.
4. The nurse is caring for a patient with a tracheostomy. What should
the nurse do if the tracheostomy tube becomes dislodged?
A. Reinsert the tube immediately
B. Call for help and apply oxygen
C. Suction the airway before reinsertions
D. Perform a rapid assessment of the airway and breathing
Answer: D. Perform a rapid assessment of the airway and breathing
Rationale: Ensuring the airway is patent is the priority. Reinsertion or
other interventions should be based on the patient's respiratory status.
, 5. A patient with diabetes is being discharged home with an insulin
regimen. Which statement by the patient indicates an understanding of
the teaching?
A. "I will take my insulin dose only when my blood sugar is high."
B. "I will store my insulin at room temperature for up to one month."
C. "I will rotate my injection sites to prevent tissue damage."
D. "I will stop taking insulin if I am feeling ill."
Answer: C. "I will rotate my injection sites to prevent tissue damage."
Rationale: Rotating injection sites prevents tissue damage and
promotes consistent absorption of insulin.
6. A nurse is caring for a patient with acute pancreatitis. Which finding
should the nurse report immediately to the healthcare provider?
A. Nausea and vomiting
B. Abdominal distention and tenderness
C. Elevated white blood cell count
D. Serum amylase and lipase levels that are significantly elevated
Answer: B. Abdominal distention and tenderness
Rationale: These findings may indicate a complication such as
pancreatic pseudocyst or perforation, which requires immediate
intervention.
at risk for delirium tremens. Which finding should the nurse report
immediately?
A. Diaphoresis
B. Tremors and anxiety
C. Hypertension and tachycardia
D. Confusion and hallucinations
Answer: D. Confusion and hallucinations
Rationale: Delirium tremens is a serious complication of alcohol
withdrawal that requires immediate treatment.
2. Which nursing action is essential when administering packed red
blood cells (PRBCs)?
A. Infuse the blood within 2 hours
B. Prime the tubing with dextrose 5%
C. Verify patient identity with another nurse
D. Monitor the patient every 30 minutes
Answer: C. Verify patient identity with another nurse
Rationale: Proper verification prevents transfusion reactions caused by
mismatched blood.
,3. A patient with chronic pain is being prescribed opioids. Which
statement indicates the need for further teaching?
A. "I should take my medication exactly as prescribed."
B. "I will take my medication with food to prevent nausea."
C. "I can stop taking the medication if I feel my pain has improved."
D. "I will monitor myself for any signs of constipation."
Answer: C. "I can stop taking the medication if I feel my pain has
improved."
Rationale: Opioid medication should be taken consistently as
prescribed. Stopping abruptly can lead to withdrawal symptoms.
4. The nurse is caring for a patient with a tracheostomy. What should
the nurse do if the tracheostomy tube becomes dislodged?
A. Reinsert the tube immediately
B. Call for help and apply oxygen
C. Suction the airway before reinsertions
D. Perform a rapid assessment of the airway and breathing
Answer: D. Perform a rapid assessment of the airway and breathing
Rationale: Ensuring the airway is patent is the priority. Reinsertion or
other interventions should be based on the patient's respiratory status.
, 5. A patient with diabetes is being discharged home with an insulin
regimen. Which statement by the patient indicates an understanding of
the teaching?
A. "I will take my insulin dose only when my blood sugar is high."
B. "I will store my insulin at room temperature for up to one month."
C. "I will rotate my injection sites to prevent tissue damage."
D. "I will stop taking insulin if I am feeling ill."
Answer: C. "I will rotate my injection sites to prevent tissue damage."
Rationale: Rotating injection sites prevents tissue damage and
promotes consistent absorption of insulin.
6. A nurse is caring for a patient with acute pancreatitis. Which finding
should the nurse report immediately to the healthcare provider?
A. Nausea and vomiting
B. Abdominal distention and tenderness
C. Elevated white blood cell count
D. Serum amylase and lipase levels that are significantly elevated
Answer: B. Abdominal distention and tenderness
Rationale: These findings may indicate a complication such as
pancreatic pseudocyst or perforation, which requires immediate
intervention.
