Question 1: A client with diabetes is experiencing confusion, sweating, and tremors. What is the nurse’s priority action?
Rationale: Confusion, sweating, and tremors suggest hypoglycemia. Checking the client’s blood glucose level confirms the diagnosis and guides treatment.
Question 2: A nurse is caring for a client with a chest tube. Which finding requires immediate intervention?
Rationale: A dislodged chest tube can lead to a pneumothorax and requires immediate intervention to reestablish the system or cover the site with a sterile dressing.
Question 3: A nurse is teaching a client about metoprolol for hypertension. Which statement by the client indicates understanding?
Rationale: Metoprolol is a beta-blocker that can cause bradycardia. Checking the heart rate before administration ensures safety.
Question 4: A client with acute pancreatitis reports severe abdominal pain radiating to the back. Which intervention is most appropriate?
Rationale: Administering prescribed opioids is appropriate to manage the severe pain associated with acute pancreatitis.
Question 5: A nurse is assessing a client with hypothyroidism. Which finding suggests the need for immediate intervention?
Rationale: Altered mental status may indicate myxedema coma, a life-threatening complication of severe hypothyroidism requiring immediate intervention.
