Question 1: A client is admitted with diabetic ketoacidosis (DKA). What is the nurse’s priority intervention?
Rationale: IV fluid replacement is the priority to correct dehydration in DKA, which can lead to severe complications.
Question 2: A client is receiving a blood transfusion and reports chills and back pain. What is the nurse’s first action?
Rationale: Stopping the transfusion is the first action to prevent further complications of a suspected transfusion reaction.
Question 3: A nurse is caring for a client who has just undergone thyroidectomy. Which assessment finding is most concerning?
Rationale: A calcium level of 7 mg/dL indicates hypocalcemia, which may occur due to accidental removal of or damage to the parathyroid glands during surgery.
Question 4: A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 L/min via nasal cannula. The client reports increasing shortness of breath. What is the nurse’s priority action?
Rationale: Checking oxygen saturation helps assess the client’s oxygenation status before making any changes to the oxygen flow rate.
Question 5: A nurse is educating a client with heart failure about dietary restrictions. Which statement by the client indicates a need for further teaching?
Rationale: Drinking excessive fluids can worsen fluid retention in clients with heart failure and should be avoided unless otherwise directed.
