Everything Nursing With Nurse Rena

Test Your Knowledge: 👇

1. The nurse enters a patient’s room and notices the patient lying on the floor. Which action should the nurse take first?

A. Document the incident
B. Assess the patient’s condition
C. Notify the healthcare provider
D. Complete an incident report

Correct Answer: B. Assess the patient’s condition

Rationale:
The priority is always to assess the patient using the nursing process (Assessment → Diagnosis → Planning → Implementation → Evaluation). Documentation and reporting come after ensuring the patient’s safety.

2. Which pulse site is most appropriate for assessing circulation during cardiopulmonary resuscitation (CPR) in an adult?

A. Radial pulse
B. Apical pulse
C. Carotid pulse
D. Brachial pulse

Correct Answer: C. Carotid pulse

Rationale:
The carotid artery is the preferred pulse site for assessing circulation during CPR because it is a central artery and remains palpable even when blood pressure is low.

3. Which nursing action demonstrates proper hand hygiene?

A. Wearing gloves instead of washing hands
B. Washing hands only after patient contact
C. Performing hand hygiene before and after patient contact
D. Washing hands only when visibly soiled

Correct Answer: C. Performing hand hygiene before and after patient contact

Rationale:
Hand hygiene is the most effective measure for preventing healthcare-associated infections and should be performed before and after every patient contact.

4. Which position is best for a patient experiencing shortness of breath?

A. Supine position
B. Trendelenburg position
C. Fowler’s position
D. Prone position

Correct Answer: C. Fowler’s position

Rationale:
Fowler’s position promotes lung expansion and facilitates breathing, making it ideal for patients with respiratory distress.

5. A nurse is preparing to administer medication. Which principle follows the “Rights” of medication administration?

A. Right room
B. Right physician
C. Right patient
D. Right diagnosis

Correct Answer: C. Right patient

Rationale:
One of the core rights of medication administration is verifying the right patient to prevent medication errors.

6. Which patient should the nurse assess first?

A. A patient with a temperature of 38°C (100.4°F)
B. A patient complaining of severe chest pain
C. A patient requesting pain medication
D. A patient scheduled for discharge

Correct Answer: B. A patient complaining of severe chest pain

Rationale:
According to priority-setting principles (ABCs), chest pain may indicate a life-threatening cardiac event and requires immediate assessment.

7. Which type of communication technique is therapeutic?

A. Giving advice
B. Changing the subject
C. Using open-ended questions
D. Providing false reassurance

Correct Answer: C. Using open-ended questions

Rationale:
Open-ended questions encourage patients to express feelings and concerns, promoting effective nurse-patient communication.

8. Which intervention helps prevent pressure injuries in bedridden patients?

A. Restricting fluid intake
B. Repositioning every 2 hours
C. Keeping the head of the bed elevated at all times
D. Massaging reddened areas

Correct Answer: B. Repositioning every 2 hours

Rationale:
Regular repositioning reduces prolonged pressure on tissues and helps prevent pressure ulcers.

9. Which route of medication administration provides the fastest absorption?

A. Oral
B. Intramuscular
C. Subcutaneous
D. Intravenous

Correct Answer: D. Intravenous

Rationale:
Intravenous administration delivers medication directly into the bloodstream, producing the fastest therapeutic effect.

10. A nurse delegates the task of obtaining vital signs to an unlicensed assistive personnel (UAP). The nurse remains responsible for:

A. Performing the task personally
B. Interpreting the results obtained
C. Documenting only abnormal findings
D. Avoiding follow-up assessment

Correct Answer: B. Interpreting the results obtained

Rationale:
Although tasks may be delegated, the nurse remains accountable for evaluating and interpreting the data and taking appropriate actions based on the findings.

📌 Disclaimer

This content is intended for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.

Jaundice occurring within the first 24 hours of life is always considered abnormal (pathologic) and requires immediate evaluation and treatment.

1. Cardiac Monitor

Question:
A nurse is caring for a patient admitted with chest pain. Which hospital device should the nurse use to continuously monitor the patient’s heart rhythm?

A. Nebulizer
B. Cardiac Monitor
C. Suction Machine
D. Infusion Pump

Answer: B. Cardiac Monitor

Rationale:
A cardiac monitor continuously displays the heart’s electrical activity, heart rate, and rhythm. It helps detect arrhythmias and other cardiac abnormalities early. Nebulizers deliver medications to the lungs, suction machines remove secretions, and infusion pumps administer fluids or medications.

2. Pulse Oximeter

Question:
A patient with pneumonia develops shortness of breath. Which device should the nurse use first to assess oxygen saturation?

A. Thermometer
B. Blood Pressure Monitor
C. Pulse Oximeter
D. ECG Machine

Answer: C. Pulse Oximeter

Rationale:
A pulse oximeter provides a quick, noninvasive measurement of oxygen saturation (SpO₂). This information helps determine if the patient requires supplemental oxygen.

3. Infusion Pump

Question:
A patient is prescribed an IV antibiotic that must be administered at a precise rate over 60 minutes. Which device should the nurse use?

A. Ventilator
B. Infusion Pump
C. Defibrillator
D. Suction Machine

Answer: B. Infusion Pump

Rationale:
An infusion pump ensures accurate and controlled delivery of medications and IV fluids, reducing the risk of under- or overdosing.

4. Ventilator

Question:
A patient in the intensive care unit is unable to breathe effectively after severe respiratory failure. Which equipment is most appropriate?

A. Ventilator
B. Nebulizer
C. Pulse Oximeter
D. Thermometer

Answer: A. Ventilator

Rationale:
A ventilator provides mechanical breathing support when patients cannot maintain adequate ventilation on their own.

5. Blood Pressure Monitor

Question:
The nurse needs to assess a patient’s blood pressure before administering an antihypertensive medication. Which device should be used?

A. ECG Machine
B. Blood Pressure Monitor
C. Cardiac Monitor
D. Oxygen Cylinder

Answer: B. Blood Pressure Monitor

Rationale:
A blood pressure monitor measures systolic and diastolic blood pressure, helping determine whether medication administration is safe and appropriate.

6. Nebulizer

Question:
A child with an acute asthma attack is prescribed inhaled bronchodilator therapy. Which device should the nurse prepare?

A. Nebulizer
B. Defibrillator
C. Wheelchair
D. ECG Machine

Answer: A. Nebulizer

Rationale:
A nebulizer converts liquid medication into a fine mist that can be inhaled into the lungs, providing rapid relief of bronchospasm.

7. Suction Machine

Question:
A patient with excessive oral secretions is unable to clear the airway effectively. Which device should the nurse use?

A. Ventilator
B. Oxygen Cylinder
C. Suction Machine
D. Infusion Pump

Answer: C. Suction Machine

Rationale:
A suction machine removes secretions, blood, or fluids from the airway, helping maintain airway patency and preventing aspiration.

8. ECG Machine

Question:
A patient reports palpitations and dizziness. Which device will help identify abnormal cardiac rhythms?

A. ECG Machine
B. Thermometer
C. Nebulizer
D. Wheelchair

Answer: A. ECG Machine

Rationale:
An ECG machine records the heart’s electrical activity and helps diagnose arrhythmias, myocardial ischemia, and other cardiac conditions.

9. Defibrillator

Question:
A patient suddenly becomes unresponsive, pulseless, and is found to be in ventricular fibrillation. Which equipment should the nurse prepare immediately?

A. Infusion Pump
B. Pulse Oximeter
C. Defibrillator
D. Thermometer

Answer: C. Defibrillator

Rationale:
Defibrillation is the priority treatment for ventricular fibrillation and pulseless ventricular tachycardia. The electrical shock may restore a perfusing cardiac rhythm.

10. Oxygen Cylinder

Question:
A patient has an SpO₂ of 86% on room air and is experiencing shortness of breath. Which equipment should the nurse anticipate using?

A. Wheelchair
B. Oxygen Cylinder
C. Hospital Bed
D. ECG Machine

Answer: B. Oxygen Cylinder

Rationale:
An oxygen cylinder provides supplemental oxygen to patients with hypoxemia. Improving oxygen delivery can help relieve respiratory distress and increase oxygen saturation levels.

Disclaimer

For educational purposes only. These NCLEX-style questions are intended to support nursing education and should not replace clinical judgment, institutional protocols, or professional medical advice.

Question 1
A 22-year-old client with sickle cell anemia arrives at the emergency department complaining of severe pain in the arms, legs, and back. The nurse notes that the client has not been drinking enough fluids due to nausea.

What is the nurse’s priority action?

A. Encourage increased fluid intake and administer prescribed pain medication
B. Restrict fluids to prevent fluid overload
C. Encourage strenuous exercise to improve circulation
D. Place the client in a cold environment

Answer: A. Encourage increased fluid intake and administer prescribed pain medication

Rationale:
A vaso-occlusive (pain) crisis is a common complication of sickle cell anemia. Dehydration can increase red blood cell sickling and worsen the crisis. Hydration and pain management are priority interventions. Restricting fluids, exercising strenuously, and exposure to cold can worsen sickling.

Question 2
A nurse is teaching a client with sickle cell anemia about preventing complications. Which statement by the client indicates understanding of the teaching?

A. “I should avoid all vaccinations.”
B. “I will drink plenty of water and avoid extreme temperatures.”
C. “I should stop exercising completely.”
D. “I should take antibiotics only when I feel sick.”

Answer: B. “I will drink plenty of water and avoid extreme temperatures.”

Rationale:
Adequate hydration and avoiding extreme heat or cold help reduce sickling episodes. Vaccinations are important because infection can trigger crises. Moderate exercise is encouraged, and medications should be taken as prescribed.

Question 3
A child with sickle cell anemia is brought to the clinic with a fever of 39°C (102.2°F). What should be the nurse’s greatest concern?

A. Increased appetite
B. Infection leading to a sickle cell crisis
C. Temporary hair loss
D. Weight gain

Answer: B. Infection leading to a sickle cell crisis

Rationale:
Clients with sickle cell anemia are at increased risk for infections due to impaired splenic function. Fever may indicate a serious infection and can trigger a sickle cell crisis. Prompt assessment and treatment are essential.

Question 4
A nurse is assessing a client with sickle cell anemia. Which finding is most consistent with anemia?

A. Hypertension and flushed skin
B. Increased energy level
C. Fatigue, pallor, and shortness of breath
D. Bradycardia and weight gain

Answer: C. Fatigue, pallor, and shortness of breath

Rationale:
Sickle cell anemia reduces the blood’s oxygen-carrying capacity. Common manifestations include fatigue, weakness, pallor, tachycardia, and shortness of breath. These symptoms result from chronic anemia.

Question 5
A client with sickle cell anemia asks why genetic counseling is recommended before having children. What is the nurse’s best response?

A. “The disease is caused by poor nutrition.”
B. “Sickle cell anemia is inherited, and counseling helps determine the risk of passing it to children.”
C. “The disease develops from infections during pregnancy.”
D. “Genetic counseling guarantees that children will not have the disease.”

Answer: B. “Sickle cell anemia is inherited, and counseling helps determine the risk of passing it to children.”

Rationale:
Sickle cell anemia is an inherited genetic disorder caused by mutations in the hemoglobin gene. Genetic counseling helps prospective parents understand inheritance patterns and the likelihood of having a child with the disease. It does not guarantee outcomes but provides important information for decision-making.

Disclaimer: These NCLEX-style questions are intended for educational purposes and should not replace professional medical advice, diagnosis, or treatment.

10 NCLEX-Style Scenario Questions on Adult Vital Signs

Question 1

A nurse is assessing a 35-year-old client during a routine checkup. The client’s temperature is 38.5°C (101.3°F). Which action should the nurse take first?

A. Document the finding as normal
B. Notify the healthcare provider immediately without further assessment
C. Assess for signs of infection and other symptoms
D. Encourage the client to exercise

Answer: C. Assess for signs of infection and other symptoms

Rationale:
A normal adult temperature is approximately 36.5°C–37.5°C (97.6°F–99.5°F). A temperature of 38.5°C indicates fever. The nurse should perform further assessment to identify possible causes such as infection before taking additional actions.

Question 2

A nurse obtains a pulse rate of 54 beats/minute in a healthy adult marathon runner who denies dizziness or weakness. How should the nurse interpret this finding?

A. Normal finding in a conditioned athlete
B. Medical emergency
C. Sign of severe infection
D. Evidence of hypertension

Answer: A. Normal finding in a conditioned athlete

Rationale:
The normal adult pulse rate is 60–100 bpm. Well-conditioned athletes may naturally have lower resting heart rates due to increased cardiovascular efficiency.

Question 3

A 60-year-old client has a respiratory rate of 28 breaths/minute. Which interpretation is most appropriate?

A. Normal finding for adults
B. Indicates tachypnea and requires further assessment
C. Indicates bradycardia
D. Indicates hypothermia

Answer: B. Indicates tachypnea and requires further assessment

Rationale:
The normal adult respiratory rate is 12–20 breaths/minute. A rate of 28 breaths/minute is tachypnea and may indicate pain, anxiety, respiratory distress, fever, or other underlying conditions.

Question 4

A nurse measures a client’s blood pressure as 118/76 mmHg. What should the nurse do?

A. Report it as severe hypertension
B. Administer antihypertensive medication immediately
C. Document it as within normal range
D. Repeat the measurement because it is too low

Answer: C. Document it as within normal range

Rationale:
A blood pressure within the range of approximately 90/60 mmHg to 120/80 mmHg is generally considered normal for adults.

Question 5

A client has an oxygen saturation (SpO₂) of 88% on room air. What is the nurse’s priority action?

A. Document as normal
B. Assess the client for signs of respiratory distress
C. Encourage the client to sleep
D. Ignore the reading and reassess in 24 hours

Answer: B. Assess the client for signs of respiratory distress

Rationale:
Normal oxygen saturation is generally 95–100%. An SpO₂ of 88% suggests hypoxemia and requires immediate assessment and possible intervention.

Question 6

A postoperative client reports pain at 8/10 on the numeric pain scale. How should the nurse classify this pain?

A. Mild pain
B. Moderate pain
C. Severe pain
D. No pain

Answer: C. Severe pain

Rationale:
On the pain scale:
• 0 = No pain
• 1–3 = Mild pain
• 4–6 = Moderate pain
• 7–10 = Severe pain

A rating of 8 indicates severe pain that requires prompt management.

Question 7

A nurse notes the following vital signs:
• Temperature: 37°C (98.6°F)
• Pulse: 84 bpm
• Respiratory rate: 18 breaths/minute
• Blood pressure: 116/74 mmHg
• SpO₂: 98%

Which finding requires intervention?

A. Temperature
B. Pulse
C. Respiratory rate
D. None of the findings

Answer: D. None of the findings

Rationale:
All values fall within normal adult ranges and do not require intervention.

Question 8

While obtaining blood pressure, a nursing student asks why the cuff should fit properly. What is the nurse’s best response?

A. An incorrect cuff size can affect the accuracy of the reading.
B. It makes the procedure faster.
C. It improves oxygen saturation.
D. It lowers the client’s blood pressure.

Answer: A. An incorrect cuff size can affect the accuracy of the reading.

Rationale:
Using the wrong cuff size may produce falsely high or falsely low blood pressure readings, leading to inaccurate assessment.

Question 9

A client has the following vital signs:
• Temperature: 36.8°C
• Pulse: 102 bpm
• Respiratory rate: 18 breaths/minute
• Blood pressure: 118/78 mmHg
• SpO₂: 97%

Which finding should the nurse investigate further?

A. Temperature
B. Pulse
C. Respiratory rate
D. Oxygen saturation

Answer: B. Pulse

Rationale:
A pulse rate greater than 100 bpm is considered tachycardia. The nurse should assess for causes such as pain, anxiety, fever, dehydration, or cardiac conditions.

Question 10

A nurse is teaching a newly hired nurse about the order of priorities during vital sign assessment. Which client should be assessed first?

A. Client with BP 118/76 mmHg
B. Client with temperature 37°C (98.6°F)
C. Client with SpO₂ 86%
D. Client with pulse 78 bpm

Answer: C. Client with SpO₂ 86%

Rationale:
Using the ABCs (Airway, Breathing, Circulation), oxygenation problems take priority. An SpO₂ of 86% indicates significant hypoxemia and requires immediate assessment and intervention.

Disclaimer

This content is intended for educational purposes only and should not replace professional medical advice, diagnosis, or treatment. Always follow current clinical guidelines and institutional policies.

5 HABITS DAMAGING YOUR KIDNEYS

Your kidneys help remove waste and extra fluid from your body. When they are damaged, your health can seriously suffer. Some daily habits may quietly destroy your kidneys without you knowing:

1. Not Drinking Enough Water
Dehydration makes it difficult for the kidneys to function properly and can increase the risk of kidney stones and infections.

2. Excessive Use of Painkillers
Frequent use of drugs like ibuprofen and diclofenac without proper medical advice can damage the kidneys over time.

3. Too Much Salt Intake
Eating excessive salty foods can raise blood pressure, which is one of the leading causes of kidney disease.

4. Ignoring High Blood Pressure or Diabetes
Poorly controlled hypertension and diabetes can slowly damage the tiny blood vessels in the kidneys.

5. Holding Urine for Too Long
Regularly delaying urination may increase the risk of urinary tract infections and kidney problems.

HOW TO PROTECT YOUR KIDNEYS

Drink enough clean water
Reduce salty and processed foods
Avoid self-medication
Check your blood pressure and blood sugar regularly
Exercise and maintain a healthy weight

Healthy kidneys contribute to a healthier life.

EVERYTHING NURSING WITH NURSE RENA

Disclaimer:
This post is for educational purposes only and does not replace professional medical advice, diagnosis, or treatment.

NCLEX-Style Questions on Ectopic Pregnancy

1. A nurse is assessing a client suspected of having an ectopic pregnancy. Which finding requires immediate intervention?

A. Mild nausea after meals
B. Breast tenderness
C. Severe lower abdominal pain with dizziness
D. Increased appetite

✅ Correct Answer: C. Severe lower abdominal pain with dizziness

Rationale:

Severe abdominal pain accompanied by dizziness may indicate a ruptured ectopic pregnancy, which can lead to life-threatening internal bleeding and shock. Immediate medical attention is required.
• Mild nausea and breast tenderness are common pregnancy symptoms.
• Increased appetite is not associated with rupture.

2. A client with an unruptured ectopic pregnancy is receiving methotrexate therapy. Which statement by the client indicates understanding of the teaching?

A. “I should return for follow-up blood tests.”
B. “I can stop treatment when the pain is gone.”
C. “This medication guarantees future fertility.”
D. “I should take folic acid supplements with this medication.”

✅ Correct Answer: A. “I should return for follow-up blood tests.”

Rationale:

Methotrexate therapy requires close monitoring of hCG levels to ensure the ectopic tissue is resolving.
• Stopping treatment early is unsafe.
• Future fertility cannot be guaranteed.
• Folic acid is usually avoided because it can interfere with methotrexate action.

3. Which client history increases the risk for ectopic pregnancy?

A. Previous pelvic inflammatory disease
B. Regular exercise
C. High fluid intake
D. Balanced diet

✅ Correct Answer: A. Previous pelvic inflammatory disease

Rationale:

Pelvic inflammatory disease can cause scarring of the fallopian tubes, increasing the risk that a fertilized egg implants outside the uterus.
• The other options do not increase ectopic pregnancy risk.

4. A nurse is teaching a client about symptoms of ectopic pregnancy. Which symptom should the nurse emphasize as requiring urgent evaluation?

A. Food cravings
B. Shoulder pain
C. Increased urination
D. Mild fatigue

✅ Correct Answer: B. Shoulder pain

Rationale:

Shoulder pain may indicate internal bleeding from a ruptured ectopic pregnancy. Blood irritating the diaphragm can cause referred shoulder pain and requires emergency care.
• The other symptoms are common in normal pregnancy.

5. Which nursing instruction is most appropriate for reducing the risk of ectopic pregnancy?

A. Avoid sleeping on the left side
B. Limit physical activity
C. Practice safe s*x and treat infections early
D. Increase sugar intake during pregnancy

✅ Correct Answer: C. Practice safe s*x and treat infections early

Rationale:

Sexually transmitted infections and untreated pelvic infections can damage the fallopian tubes and increase the risk of ectopic pregnancy. Safe s*xual practices and early treatment help reduce this risk.
• The remaining options are unrelated to prevention of ectopic pregnancy.

Follow Everything Nursing With Nurse Rena for more educational nursing content.

⚠️ DISCLAIMER: This content is for educational and awareness purposes only and should not replace professional medical advice, diagnosis, or treatment. Please consult a qualified healthcare provider for any medical concerns or emergencies.

If you’re learning something from this page, please support by engaging with the posts ❤️
A comment, share, or even a simple like 👍 goes a long way. Thank you all for the love and support. I truly appreciate every one of you 😊

1. A nurse is using the Rule of Nines to estimate burn size in an adult client. Which body area represents 18% of the total body surface area (TBSA)?

A. Head and neck
B. One arm
C. Anterior trunk
D. Perineum

Correct Answer: C. Anterior trunk

Rationale:
In adults, the anterior trunk accounts for 18% of TBSA according to the Rule of Nines.
• Head and neck = 9%
• One arm = 9%
• Perineum = 1%

2. A client has burns on the entire left arm and anterior trunk. Using the Rule of Nines, what percentage of TBSA is burned?

A. 18%
B. 27%
C. 36%
D. 45%

Correct Answer: B. 27%

Rationale:
• Entire left arm = 9%
• Anterior trunk = 18%
Total = 27%

3. Which finding is the nurse’s priority in a client with major burns?

A. Anxiety
B. Pain
C. Airway compromise
D. Risk for infection

Correct Answer: C. Airway compromise

Rationale:
Airway always comes first using the ABCs (Airway, Breathing, Circulation). Burn clients, especially those with facial burns or smoke inhalation, are at high risk for airway edema and obstruction.

4. A nurse assesses a burn client with singed nasal hairs and soot around the mouth. What should the nurse suspect?

A. Internal bleeding
B. Inhalation injury
C. Spinal cord injury
D. Hypoglycemia

Correct Answer: B. Inhalation injury

Rationale:
Signs such as singed nasal hairs, hoarseness, soot around the mouth, and facial burns strongly suggest inhalation injury, which can rapidly lead to airway obstruction.

5. According to the Rule of Nines, what percentage is assigned to one entire leg in an adult?

A. 9%
B. 18%
C. 27%
D. 36%

Correct Answer: B. 18%

Rationale:
Each entire leg represents 18% of TBSA in adults:
• Front = 9%
• Back = 9%

6. Which fluid replacement formula is commonly used in burn management?

A. Glasgow formula
B. Parkland formula
C. Apgar formula
D. Braden formula

Correct Answer: B. Parkland formula

Rationale:
The Parkland formula helps determine fluid resuscitation needs in burn patients during the first 24 hours after injury.

7. A nurse explains that the Rule of Nines is primarily used for which purpose?

A. Measuring pain intensity
B. Determining burn depth
C. Estimating burned body surface area
D. Assessing level of consciousness

Correct Answer: C. Estimating burned body surface area

Rationale:
The Rule of Nines estimates the percentage of TBSA affected by burns, helping guide treatment decisions and fluid replacement.

8. Which burn client is at greatest risk for hypovolemic shock?

A. Client with superficial finger burns
B. Client with 40% TBSA burns
C. Client with a small facial burn
D. Client with a first-degree sunburn

Correct Answer: B. Client with 40% TBSA burns

Rationale:
Large burns cause massive fluid loss from damaged capillaries, increasing the risk for hypovolemic shock.

9. Which statement by a nursing student indicates correct understanding of burn depth?

A. “First-degree burns destroy muscle tissue.”
B. “Third-degree burns may appear painless.”
C. “Second-degree burns affect only the epidermis.”
D. “Superficial burns always require skin grafts.”

Correct Answer: B. “Third-degree burns may appear painless.”

Rationale:
Third-degree (full-thickness) burns destroy nerve endings, which can make the area painless despite severe tissue damage.

10. A client has burns to the head, neck, and one entire arm. What is the estimated TBSA burned?

A. 9%
B. 18%
C. 27%
D. 36%

Correct Answer: B. 18%

Rationale:
• Head and neck = 9%
• One entire arm = 9%
Total = 18%

✨ Follow “Everything Nursing With Nurse Rena” for more NCLEX-style nursing content and simplified medical education!

Disclaimer:
⚠️ This content is for educational and awareness purposes only and should not replace professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider for proper medical care.

1. A nurse is teaching a client about hypertension. Which statement by the client indicates understanding?

A. “Hypertension always causes severe headaches.”
B. “I can stop my medication once my blood pressure is normal.”
C. “Hypertension can damage organs if left uncontrolled.”
D. “Only older adults develop hypertension.”

Answer: C

Rationale:
Hypertension is called the “silent killer” because it may not cause symptoms but can damage organs such as the heart, brain, kidneys, and eyes if uncontrolled.

2. Which blood pressure reading indicates Stage 2 hypertension?

A. 118/76 mmHg
B. 126/78 mmHg
C. 134/86 mmHg
D. 148/94 mmHg

Answer: D

Rationale:
Stage 2 hypertension is a systolic BP of 140 mmHg or higher or a diastolic BP of 90 mmHg or higher.

3. A client with hypertension reports dizziness when standing. What is the nurse’s priority action?

A. Encourage rapid position changes
B. Assess the client’s blood pressure
C. Restrict fluid intake
D. Administer another antihypertensive medication

Answer: B

Rationale:
Dizziness upon standing may indicate orthostatic hypotension. The nurse should first assess blood pressure and evaluate the client before further interventions.

4. Which lifestyle modification should the nurse recommend to help control hypertension?

A. Increase sodium intake
B. Limit physical activity
C. Stop smoking
D. Drink more alcohol

Answer: C

Rationale:
Smoking increases blood pressure and cardiovascular risk. Quitting smoking is an important intervention for hypertension management.

5. A nurse is caring for a client experiencing hypertensive crisis. Which BP reading would the nurse expect?

A. 118/70 mmHg
B. 128/82 mmHg
C. 150/88 mmHg
D. 190/124 mmHg

Answer: D

Rationale:
A hypertensive crisis occurs when blood pressure is extremely elevated, usually above 180/120 mmHg, requiring immediate medical attention.

6. Which food choice by a client with hypertension indicates a need for further teaching?

A. Fresh fruits
B. Grilled fish
C. Canned soup
D. Steamed vegetables

Answer: C

Rationale:
Canned soups are often high in sodium, which can worsen hypertension.

7. Which organ is most at risk for damage from uncontrolled hypertension?

A. Skin
B. Kidneys
C. Pancreas
D. Appendix

Answer: B

Rationale:
Uncontrolled hypertension can damage blood vessels in the kidneys, leading to kidney disease or renal failure.

8. A client asks why antihypertensive medications must be taken daily. Which response by the nurse is best?

A. “You only need them when symptoms occur.”
B. “They help control blood pressure consistently.”
C. “They cure hypertension permanently.”
D. “They work immediately and then stop working.”

Answer: B

Rationale:
Antihypertensive medications help maintain blood pressure within a safe range and should be taken regularly as prescribed.

9. Which assessment finding is commonly associated with hypertension?

A. Bradycardia
B. Nosebleeds
C. Low urine output only
D. Hypoglycemia

Answer: B

Rationale:
Some clients with hypertension may experience headaches, dizziness, blurred vision, or nosebleeds, although many remain asymptomatic.

10. The nurse is teaching a client about the DASH diet. Which statement indicates correct understanding?

A. “I should eat more salty foods.”
B. “I should increase fruits and vegetables in my meals.”
C. “Processed foods are recommended.”
D. “Exercise is not necessary if I follow the diet.”

Answer: B

Rationale:
The DASH diet emphasizes fruits, vegetables, whole grains, and low-fat foods while reducing sodium intake to help lower blood pressure.

Follow Everything Nursing With Nurse Rena for more educational content ❤️