Question 1: A client with heart failure reports a weight gain of 5 pounds in 3 days. What is the nurse’s priority action?
Rationale: Assessing lung sounds and edema is the priority to determine the extent of fluid overload and guide interventions.
Question 2: A nurse is caring for a client with a sodium level of 120 mEq/L. What clinical manifestation would the nurse expect?
Rationale: Hyponatremia (low sodium levels) can cause muscle cramps, weakness, and neurological symptoms.
Question 3: A nurse is teaching a client about insulin administration. Which statement indicates the client understands the teaching?
Rationale: Rotating injection sites prevents lipodystrophy, a condition that can affect insulin absorption.
Question 4: A client with a history of seizures reports an aura. What is the nurse’s priority action?
Rationale: Placing the client in a side-lying position is the priority to maintain airway patency during a potential seizure.
Question 5: A client is prescribed albuterol for asthma. Which side effect should the nurse teach the client to expect?
Rationale: Tachycardia is a common side effect of albuterol, a beta-agonist bronchodilator.
