Question 1: A nurse is assessing a client with hypovolemic shock. Which finding is most concerning?
Rationale: Urine output of 10 mL/hour indicates inadequate kidney perfusion, requiring immediate intervention to restore circulating volume.
Question 2: A client is admitted with a suspected stroke. Which intervention should the nurse prioritize?
Rationale: A CT scan must be performed immediately to differentiate between ischemic and hemorrhagic stroke and guide treatment.
Question 3: A client is receiving intravenous vancomycin. Which assessment finding requires immediate action?
Rationale: Widespread flushing may indicate "Red Man Syndrome," a reaction to rapid vancomycin infusion, requiring immediate intervention.
Question 4: A client with atrial fibrillation is prescribed warfarin. Which client statement indicates a need for further teaching?
Rationale: Monitoring blood pressure is not directly relevant to warfarin therapy and indicates a misunderstanding of its purpose.
Question 5: A nurse is caring for a client receiving continuous bladder irrigation following prostate surgery. Which finding requires immediate intervention?
Rationale: Bright red output indicates active bleeding and requires immediate intervention to prevent further complications.
