Question 1: A nurse is caring for a client with liver cirrhosis. Which finding requires immediate intervention?
Rationale: Blood in the stool indicates gastrointestinal bleeding, a serious complication of liver cirrhosis requiring immediate intervention.
Question 2: A client receiving morphine for pain relief has a respiratory rate of 8 breaths per minute. What is the nurse’s priority action?
Rationale: A respiratory rate of 8 indicates respiratory depression, and naloxone should be administered immediately to reverse the effects of morphine.
Question 3: A nurse is preparing to administer digoxin to a client. Which assessment finding would cause the nurse to hold the medication?
Rationale: Digoxin should be held if the client’s heart rate is below 60 beats per minute to prevent bradycardia.
Question 4: A nurse is teaching a client with chronic kidney disease about dietary restrictions. Which statement indicates the need for further teaching?
Rationale: Clients with chronic kidney disease often need to limit protein intake to reduce the burden on the kidneys, unless otherwise directed.
Question 5: A client is experiencing a tonic-clonic seizure. What is the nurse’s priority intervention?
Rationale: Protecting the client’s head and airway is the priority during a seizure to prevent injury and ensure oxygenation.
