A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD).
Which of the following interventions is most appropriate for promoting effective
breathing patterns?
A. Encourage the patient to breathe through the nose only.
B. Teach the patient to use pursed-lip breathing.
C. Instruct the patient to take rapid, shallow breaths.
D. Use oxygen therapy liberally without checking saturation levels.
Answer: B. Teach the patient to use pursed-lip breathing.
Rationale: Pursed-lip breathing helps to slow down breathing, keep airways open longer, and
improve gas exchange, making it particularly beneficial for patients with COPD.
Question 2:
A patient presents with symptoms of hyperglycemia. Which laboratory result would the
nurse expect to see?
A. Elevated fasting blood glucose
B. Decreased HbA1c
C. Low serum glucose level
D. Normal blood urea nitrogen (BUN)
Answer: A. Elevated fasting blood glucose
Rationale: An elevated fasting blood glucose level is indicative of hyperglycemia, which is
commonly seen in diabetes and other metabolic disorders.
Question 3:
A nurse is assessing a patient who is experiencing chest pain. Which finding would be
most concerning and indicative of potential myocardial infarction?
A. Pain radiating to the left arm
B. Pain relieved by nitroglycerin
C. Pain lasting less than 5 minutes
D. Pain described as sharp and localized
,Answer: A. Pain radiating to the left arm
Rationale: Chest pain that radiates to the left arm is a classic symptom of myocardial
infarction and should be treated as a priority for further evaluation and intervention.
Question 4:
A patient is being discharged after treatment for deep vein thrombosis (DVT). Which
teaching point is most important for the nurse to include?
A. "You can stop anticoagulation therapy once you feel better."
B. "You should wear compression stockings as prescribed."
C. "Avoid all physical activity for the next month."
D. "You can travel by plane as soon as you're discharged."
Answer: B. "You should wear compression stockings as prescribed."
Rationale: Wearing compression stockings helps prevent the recurrence of DVT by
promoting venous return and reducing the risk of swelling and clot formation.
Question 5:
A nurse is caring for a patient who has just undergone a lumbar laminectomy. Which
assessment finding would require immediate intervention?
A. Clear cerebrospinal fluid (CSF) drainage from the incision site
B. Severe headache and nausea
C. Decreased sensation in the legs
D. Mild swelling at the surgical site
Answer: A. Clear cerebrospinal fluid (CSF) drainage from the incision site
Rationale: Clear drainage that is consistent with cerebrospinal fluid indicates a potential leak
and requires immediate medical attention to prevent complications such as infection or
meningitis.
Question 6:
A patient with renal failure is on a potassium-restricted diet. Which food should the
nurse recommend avoiding?
A. Apples
B. Potatoes
C. Carrots
, D. Green beans
Answer: B. Potatoes
Rationale: Potatoes are high in potassium and should be avoided by patients on a potassium-
restricted diet due to the risk of hyperkalemia.
Question 7:
During a health assessment, a patient reports difficulty swallowing. What should the
nurse assess for next?
A. Risk of aspiration
B. Nutritional status
C. Presence of abdominal pain
D. History of recent weight loss
Answer: A. Risk of aspiration
Rationale: Difficulty swallowing (dysphagia) poses a risk for aspiration, which can lead to
respiratory complications, making it a priority for assessment.
Question 8:
A patient diagnosed with heart failure is experiencing edema and weight gain. Which
nursing intervention is most appropriate?
A. Increase sodium intake to prevent dehydration.
B. Encourage the patient to rest and limit activity.
C. Administer diuretics as prescribed.
D. Monitor blood pressure frequently.
Answer: C. Administer diuretics as prescribed.
Rationale: Diuretics help reduce fluid overload in heart failure patients by promoting urine
output, which alleviates symptoms such as edema and weight gain.
Question 9:
A nurse is preparing to administer a blood transfusion. Which action is the priority
before starting the transfusion?
A. Obtain vital signs before the transfusion.
B. Ensure informed consent is signed.
, C. Verify blood product with another nurse.
D. Pre-medicate with antihistamines.
Answer: C. Verify blood product with another nurse.
Rationale: The verification of blood products with another nurse is a critical safety measure
to prevent transfusion reactions and ensure the correct product is administered to the correct
patient.
Question 10:
A patient with chronic liver disease presents with jaundice. Which laboratory finding
would the nurse expect?
A. Elevated serum bilirubin levels
B. Decreased alkaline phosphatase
C. Normal liver enzymes
D. Elevated protein levels
Answer: A. Elevated serum bilirubin levels
Rationale: Jaundice occurs when there is an accumulation of bilirubin in the bloodstream,
commonly due to liver dysfunction or hemolysis, leading to elevated serum bilirubin levels.
Question 11:
A nurse is providing discharge teaching for a patient with hypertension. Which
statement by the patient indicates a need for further education?
A. "I can continue to eat my favorite foods as long as I take my medications."
B. "I should check my blood pressure regularly."
C. "I will exercise for at least 30 minutes most days of the week."
D. "I need to reduce my sodium intake."
Answer: A. "I can continue to eat my favorite foods as long as I take my medications."
Rationale: Patients with hypertension should be educated about the importance of dietary
modifications, including reducing sodium intake, in addition to taking medications.
Question 12:
A nurse is assessing a patient who is receiving chemotherapy. Which symptom should
the nurse monitor for that indicates a potential complication?
A. Nausea and vomiting
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