Question 1: A client receiving total parenteral nutrition (TPN) develops a fever. What is the nurse’s priority action?
Rationale: Checking the catheter insertion site for signs of infection is the priority to identify a potential central line-associated bloodstream infection (CLABSI).
Question 2: A client with newly diagnosed hypertension is prescribed lisinopril. Which side effect requires immediate attention?
Rationale: Swelling of the lips and face may indicate angioedema, a potentially life-threatening side effect of ACE inhibitors like lisinopril.
Question 3: A nurse is caring for a client with a potassium level of 6.8 mEq/L. Which intervention is the priority?
Rationale: Placing the client on a cardiac monitor is the priority to detect life-threatening arrhythmias associated with hyperkalemia.
Question 4: A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about pursed-lip breathing. What is the primary purpose of this technique?
Rationale: Pursed-lip breathing helps promote carbon dioxide elimination by prolonging exhalation and preventing air trapping.
Question 5: A client recovering from surgery reports nausea and vomiting. Which action should the nurse perform first?
Rationale: Placing the client in a side-lying position reduces the risk of aspiration, which is a priority when managing nausea and vomiting.
