Question 1: A nurse is assessing a client with bacterial meningitis. Which finding requires immediate action?
Rationale: A petechial rash suggests potential meningococcal sepsis, a life-threatening complication requiring immediate intervention.
Question 2: A client with chronic kidney disease has a potassium level of 6.5 mEq/L. What is the nurse’s priority action?
Rationale: Placing the client on a cardiac monitor is the priority as hyperkalemia increases the risk of life-threatening arrhythmias.
Question 3: A nurse is preparing to administer digoxin. Which finding prompts the nurse to hold the medication?
Rationale: Digoxin should be held if the client’s heart rate is below 60 beats per minute to avoid bradycardia.
Question 4: A client is receiving morphine for severe pain. Which assessment finding requires immediate intervention?
Rationale: A respiratory rate of 8 indicates respiratory depression, a serious side effect of morphine requiring immediate intervention.
Question 5: A client with newly diagnosed hypertension is prescribed hydrochlorothiazide. What should the nurse include in the teaching?
Rationale: Hydrochlorothiazide is a diuretic, so increased urination is a common side effect that clients should expect and be prepared for.
