Question 1: A client with a history of asthma presents with audible wheezing and difficulty speaking in complete sentences. What is the nurse’s priority action?
Rationale: Administering a prescribed bronchodilator is the priority to relieve airway obstruction and reduce wheezing in an asthma exacerbation.
Question 2: A client with diabetes is scheduled for surgery and has a blood glucose level of 250 mg/dL. What is the nurse’s priority action?
Rationale: Administering prescribed insulin is the priority to lower blood glucose and reduce the risk of perioperative complications.
Question 3: A nurse is caring for a client who just returned from a cardiac catheterization. Which assessment finding requires immediate intervention?
Rationale: A cool, pale extremity distal to the insertion site suggests impaired circulation and requires immediate intervention.
Question 4: A client with hypothyroidism is prescribed levothyroxine. What statement by the client indicates a need for further teaching?
Rationale: Levothyroxine is a lifelong therapy for hypothyroidism and should not be discontinued, even if symptoms improve.
Question 5: A client is prescribed lisinopril for hypertension. Which side effect should the nurse teach the client to report immediately?
Rationale: Swelling of the lips or face indicates angioedema, a potentially life-threatening side effect of ACE inhibitors like lisinopril.
