Question 1: A nurse is caring for a client with acute pancreatitis. Which assessment finding is most concerning?
Rationale: A bluish discoloration around the umbilicus (Cullen's sign) may indicate internal bleeding, a serious complication of acute pancreatitis.
Question 2: A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The client reports shortness of breath. What is the nurse’s priority action?
Rationale: Checking oxygen saturation is the priority to assess the client’s oxygenation status before adjusting therapy.
Question 3: A nurse is caring for a client with a diagnosis of myasthenia gravis. Which intervention is most important for this client?
Rationale: Administering medications at the prescribed times is crucial to maintain muscle strength and prevent complications in clients with myasthenia gravis.
Question 4: A nurse is assessing a client with a new colostomy. Which finding indicates a complication?
Rationale: A dark purple stoma indicates compromised blood flow, which is a medical emergency requiring immediate intervention.
Question 5: A client with a history of asthma is prescribed albuterol. Which statement by the client indicates effective teaching?
Rationale: Clients should wait at least 30 seconds to 1 minute between puffs to allow the first dose to take effect before administering a second dose.
