Question 1: A client with asthma is experiencing shortness of breath and wheezing. What is the nurse’s priority action?
Rationale: Administering albuterol, a fast-acting bronchodilator, is the priority to relieve bronchospasm and improve airflow.
Question 2: A client is admitted with acute pancreatitis. Which laboratory result is most concerning?
Rationale: Hypocalcemia can lead to tetany and other complications, making it the most concerning finding in acute pancreatitis.
Question 3: A client with a urinary tract infection (UTI) reports flank pain and a fever of 102°F (38.9°C). What is the nurse’s priority action?
Rationale: Administering prescribed antibiotics is the priority to address a potential progression to pyelonephritis and prevent sepsis.
Question 4: A nurse is assessing a client with hypothyroidism. Which finding suggests the client may be developing myxedema coma?
Rationale: Altered mental status is a critical sign of myxedema coma, a life-threatening complication of severe hypothyroidism.
Question 5: A client receiving warfarin therapy for atrial fibrillation has an INR of 4.2. What is the nurse’s priority action?
Rationale: An INR of 4.2 is above the therapeutic range, increasing the risk of bleeding. Holding the next dose of warfarin prevents further elevation.
