Question 1: A client with a diagnosis of heart failure reports a weight gain of 5 pounds in 3 days. What is the nurse’s priority action?
Rationale: Evaluating lung sounds and edema helps assess for fluid overload, which is critical in heart failure management.
Question 2: A nurse is caring for a client with cirrhosis. Which finding indicates the development of hepatic encephalopathy?
Rationale: Asterixis is a hallmark sign of hepatic encephalopathy due to elevated ammonia levels affecting the nervous system.
Question 3: A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 4 L/min. The client becomes drowsy and confused. What is the nurse’s priority action?
Rationale: Lowering the oxygen flow rate prevents suppression of the respiratory drive, which can occur in clients with COPD.
Question 4: A client with a new diagnosis of diabetes mellitus is learning about insulin injections. Which statement by the client indicates understanding of the teaching?
Rationale: Rotating injection sites prevents lipodystrophy and ensures better absorption of insulin.
Question 5: A nurse is caring for a client with sepsis who is receiving intravenous fluids and antibiotics. Which finding requires immediate intervention?
Rationale: A serum lactate level above 2 mmol/L indicates poor tissue perfusion and the need for aggressive resuscitation in sepsis management.
