,1. Multiple Choice: Which of the following is a priority
nursing intervention for a client with congestive heart
failure?
a) Encouraging ambulation
b) Fluid restriction
c) High sodium diet
d) Weight training exercises
Correct Answer: b) Fluid restriction
Rationale: Fluid restriction is essential to prevent volume
overload, which can exacerbate heart failure symptoms.
2. Fill-in-the-Blank: A client with type 1 diabetes mellitus is
experiencing diabetic ketoacidosis. The nurse should
administer ________ to correct the metabolic acidosis.
Correct Answer: IV insulin
Rationale: IV insulin is used to lower blood glucose levels
and correct the acidotic state in diabetic ketoacidosis.
3. True/False: In a client with acute renal failure,
hyperkalemia is a common finding.
Correct Answer: True
Rationale: Acute renal failure can lead to an accumulation
of potassium in the blood, resulting in hyperkalemia.
, d) Increase fluid intake
Correct Answers: a) Administer anticoagulants, b)
Provide supplemental oxygen, c) Initiate bed rest
Rationale: These interventions help to prevent further clot
formation, improve oxygenation, and reduce the risk of
dislodging the clot.
5. Multiple Choice: The nurse recognizes that which of the
following symptoms in a client with pneumonia requires
immediate attention?
a) Cough
b) Fever
c) Sudden onset of confusion
d) Muscle aches
Correct Answer: c) Sudden onset of confusion
Rationale: Sudden onset of confusion may indicate sepsis
or hypoxia, which requires immediate intervention.
6. Fill-in-the-Blank: The most effective method for
preventing hospital-acquired infections is ________.
Correct Answer: hand hygiene
Rationale: Hand hygiene is the most important measure
to prevent the spread of infections in healthcare settings.
7. True/False: A nurse should delegate the initial
assessment of a client to an unlicensed assistive personnel
(UAP).
Correct Answer: False
Rationale: The initial assessment is a critical component
of nursing care and must be performed by a licensed nurse.
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