Question 1: A client is scheduled for a colonoscopy. Which statement indicates the client understands the preparation instructions?
Rationale: Clients preparing for a colonoscopy should drink clear liquids the day before to ensure the colon is clear for visualization.
Question 2: A nurse is caring for a client with pneumonia. Which intervention is most effective in helping the client clear secretions?
Rationale: Encouraging frequent coughing helps mobilize and clear secretions from the lungs in clients with pneumonia.
Question 3: A client with chronic kidney disease has a potassium level of 6.2 mEq/L. What is the nurse’s priority action?
Rationale: The physician must be notified immediately, because this is potentially life-threatening
Question 4: A client is receiving a blood transfusion. The nurse observes itching and hives. What should the nurse do first?
Rationale: Stopping the transfusion immediately is the first step when a client shows signs of a transfusion reaction.
Question 5: Which assessment finding in a client with heart failure requires immediate intervention?
Rationale: A weight gain of 5 pounds in 2 days suggests fluid retention and worsening heart failure, requiring immediate intervention.
