Question 1: A nurse is assessing a client with suspected meningitis. Which finding requires immediate action?
Rationale: A petechial rash indicates possible meningococcal sepsis, requiring immediate intervention to prevent life-threatening complications.
Question 2: A nurse is teaching a client with hypertension about lifestyle modifications. Which statement indicates a need for further teaching?
Rationale: Complete avoidance of alcohol is not necessary; moderate consumption (1 drink per day for women, 2 for men) is often acceptable in controlled hypertension.
Question 3: A client with a chest tube in place reports increased shortness of breath. What is the nurse’s priority action?
Rationale: Assessing the chest tube for kinks or blockages is the priority to ensure proper drainage and prevent complications like tension pneumothorax.
Question 4: A client with hypothyroidism is started on levothyroxine. Which statement by the client indicates an understanding of the medication?
Rationale: Periodic blood tests are necessary to monitor thyroid hormone levels and adjust the dose of levothyroxine accordingly.
Question 5: A nurse is preparing to administer potassium chloride intravenously to a client with hypokalemia. What is the nurse’s priority action?
Rationale: Potassium chloride must always be infused using an IV pump to ensure controlled administration and prevent cardiac complications.
