Question 1: A nurse is assessing a client with left-sided heart failure. Which finding is most concerning?
Rationale: Crackles in the lungs indicate pulmonary congestion, a critical symptom of worsening left-sided heart failure.
Question 2: A client with chronic kidney disease has a hemoglobin level of 8 g/dL. What is the priority intervention?
Rationale: Erythropoietin is often prescribed to clients with chronic kidney disease to stimulate red blood cell production and improve anemia.
Question 3: A client with an NG tube for decompression reports nausea. What is the nurse’s initial action?
Rationale: Checking the patency of the NG tube ensures it is functioning properly to relieve gastric distention and reduce nausea.
Question 4: A client receiving a continuous IV heparin infusion has an aPTT of 90 seconds. What is the nurse’s priority action?
Rationale: An aPTT of 90 seconds is above the therapeutic range. The priority action is to stop the infusion to prevent bleeding complications.
Question 5: A nurse is preparing to administer a blood transfusion. What action should the nurse perform first?
Rationale: Verifying client identification and blood compatibility is the first and most critical step to prevent transfusion reactions.
