Question 1: A nurse is assessing a client with pneumonia. Which finding indicates the need for immediate intervention?
Rationale: An oxygen saturation of 86% indicates hypoxemia, requiring immediate intervention to improve oxygenation.
Question 2: A client with a history of atrial fibrillation is prescribed warfarin. Which instruction is most important for the nurse to provide?
Rationale: Reporting unusual bruising or bleeding is crucial for clients on warfarin as it may indicate excessive anticoagulation.
Question 3: A client is experiencing nausea after surgery. What is the nurse’s priority action?
Rationale: Assessing bowel sounds is the priority to rule out paralytic ileus or other complications before treating nausea.
Question 4: A client with a new diagnosis of type 2 diabetes asks about managing blood sugar. Which statement by the client indicates a need for further teaching?
Rationale: Skipping meals can cause blood sugar fluctuations and should be avoided to maintain glycemic control.
Question 5: A nurse is caring for a client receiving a blood transfusion. Which finding indicates a possible transfusion reaction?
Rationale: Back pain can indicate a hemolytic transfusion reaction and should be reported immediately.
