Question 1: A client with heart failure is prescribed furosemide. Which finding requires immediate intervention?
Rationale: A potassium level of 2.8 mEq/L indicates hypokalemia, a serious side effect of furosemide, which requires immediate intervention.
Question 2: A nurse is preparing to administer a blood transfusion. What is the nurse’s priority action?
Rationale: Verifying the client’s blood type and matching it with the donor unit is the priority to prevent a hemolytic reaction.
Question 3: A client with type 1 diabetes reports nausea, vomiting, and abdominal pain. What is the nurse’s priority action?
Rationale: Checking the blood glucose level is the priority to determine if the symptoms are due to diabetic ketoacidosis (DKA).
Question 4: A nurse is caring for a client with pneumonia who has a productive cough and a temperature of 101.8°F (38.8°C). What is the priority intervention?
Rationale: Assessing oxygen saturation is the priority to evaluate the client’s respiratory status and guide treatment.
Question 5: A client with a deep vein thrombosis (DVT) is receiving heparin. Which finding should the nurse report immediately?
Rationale: An aPTT of 90 seconds is above the therapeutic range and increases the risk of bleeding, requiring immediate adjustment of the heparin dose.
