Category 1
A client with an acute MI reports crushing chest pain. Which assessment finding requires immediate intervention?
A. BP 150/90
B. HR 102 bpm
C. ST elevation on ECG
D. Troponin elevation
Answer: C. ST elevation on ECG
Rationale: ST-segment elevation indicates ongoing myocardial injury and is a sign of STEMI requiring immediate reperfusion. Elevated troponin confirms damage but does not guide urgent intervention. BP and HR are important but not as immediately critical as ECG changes indicating infarction.
Which lab value is most concerning in a client with CKD?
A. Potassium 5.9 mEq/L
B. Creatinine 3.2 mg/dL
C. Hemoglobin 10.1 g/dL
D. Phosphorus 4.8 mg/dL
Answer: A. Potassium 5.9 mEq/L
Rationale: Hyperkalemia (>5.5 mEq/L) is immediately life-threatening due to risk of cardiac arrhythmias. Elevated creatinine is chronic, not immediately life-threatening.
A client with T6 spinal cord injury develops autonomic dysreflexia. Which actions should the nurse take? (Select all that apply.)
A. Sit the client upright
B. Loosen tight clothing
C. Check for bladder distention
D. Lower the head of bed
E. Notify provider
Answer: A, B, C, E
Rationale: Autonomic dysreflexia is a medical emergency; elevate head to lower BP, remove triggers (clothing, bladder distention), and notify provider. Lowering the head is not indicated.
A client with acute kidney injury has a urine output of 180 mL over 24 hours. Which action should the nurse take first?
A. Administer a loop diuretic
B. Restrict all fluids
C. Assess fluid status and electrolytes
D. Prepare the client for dialysis
Answer: C
Rationale: Assessing fluid status and electrolytes is priority to determine if the client is oliguric vs. volume overloaded. Interventions depend on assessment data.
A client with cirrhosis is at risk for which complications? (Select all that apply.)
A. Esophageal varices
B. Hepatic encephalopathy
C. Portal hypertension
D. Hypoglycemia
E. Ascites
Answer: A, B, C, E
Rationale: Liver dysfunction leads to portal hypertension, varices, fluid accumulation, and neurologic changes (encephalopathy). Hypoglycemia is not common unless malnutrition or acute liver failure occurs.
(SATA – Heart Failure)
A nurse is assessing a client with left-sided heart failure. Which findings are expected? (Select all that apply.)
A. Crackles
B. Peripheral edema
C. Orthopnea
D. Pink frothy sputum
E. Jugular vein distention
Answer: A, C, D
Rationale: Left-sided HF leads to pulmonary congestion. Crackles, orthopnea, and pink frothy sputum are classic findings. Peripheral edema and JVD are more indicative of right-sided heart failure.
A client has peaked T waves on ECG. Which electrolyte imbalance is suspected?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
Answer: B. Hyperkalemia
Rationale: Peaked T waves are classic ECG findings in hyperkalemia and require urgent intervention to prevent cardiac arrest.
Carbidopa-levodopa primarily improves:
A. Memory
B. Muscle strength
C. Motor function
D. Seizure control
Answer: C. Motor function
Rationale: Carbidopa-levodopa increases dopamine, improving tremor, rigidity, and bradykinesia. It does not affect cognition, strength, or seizures.
A client with chronic kidney disease is at risk for which complications? (Select all that apply.)
A. Hyperkalemia
B. Anemia
C. Hypocalcemia
D. Fluid overload
E. Hyperglycemia
Answer: A, B, C, D
Rationale: CKD can cause hyperkalemia, anemia (decreased erythropoietin), hypocalcemia (altered vitamin D metabolism), and fluid overload. Hyperglycemia is not a direct complication.
A client has severe right upper quadrant pain radiating to the right shoulder, nausea, and vomiting after a fatty meal. What is the priority action?
A. Administer antacids
B. Prepare for cholecystectomy
C. Monitor liver enzymes
D. Apply warm compress to RUQ
Answer: B
Rationale: The client likely has acute cholecystitis or gallstones causing obstruction. Surgical intervention is often required if pain is severe and persistent.
A client presents with sudden right-sided weakness and slurred speech. What is the priority action?
A. Administer aspirin
B. Obtain a CT scan
C. Lower blood pressure
D. Start IV fluids
Answer: B. Obtain a CT scan
Rationale: Rapid neuro assessment and CT scan are essential to differentiate ischemic vs hemorrhagic stroke before administering interventions like tPA. Administering aspirin before imaging could be harmful if hemorrhagic.
A client with cirrhosis is at risk for which complications? (Select all that apply.)
A. Esophageal varices
B. Hepatic encephalopathy
C. Portal hypertension
D. Hypoglycemia
E. Ascites
Answer: A, B, C, E
Rationale: Cirrhosis leads to portal hypertension, ascites, varices, and impaired ammonia metabolism causing encephalopathy. Hypoglycemia is less common; hyperglycemia may occur due to insulin resistance.
Which finding indicates diabetic ketoacidosis?
A. Fruity breath
B. Slow respirations
C. Hypoglycemia
D. Bradycardia
Answer: A. Fruity breath
Rationale: DKA presents with hyperglycemia, ketosis, and metabolic acidosis. Fruity breath is due to acetone. Respirations are usually Kussmaul (deep, rapid), not slow.
A client presents with Kussmaul respirations, fruity breath, and blood glucose of 480 mg/dL. ABG shows pH 7.25, HCO₃⁻ 16 mEq/L. What is the priority nursing action?
A. Administer IV insulin and fluids
B. Give sodium bicarbonate IV
C. Encourage oral hydration
D. Apply oxygen via nasal cannula
Answer: A
Rationale: The client is in diabetic ketoacidosis (metabolic acidosis). Priority is correcting hyperglycemia and dehydration with IV insulin and fluids.
Which lab finding is most specific for acute pancreatitis?
A. Elevated amylase
B. Elevated lipase
C. Elevated ALT
D. Elevated AST
Answer: B
Rationale: Lipase is more specific than amylase for diagnosing pancreatitis. ALT and AST indicate liver/biliary involvement.
Which finding indicates Cushing’s triad?
A. Hypotension, tachycardia, fever
B. Hypertension, bradycardia, irregular respirations
C. Tachycardia, bounding pulses, headache
D. Narrow pulse pressure, bradypnea, confusion
Answer: B. Hypertension, bradycardia, irregular respirations
Rationale: Cushing’s triad is a late sign of increased ICP: systolic hypertension with widening pulse pressure, bradycardia, and irregular respirations. Early recognition is critical to prevent brain herniation.
Which medication is given to reduce ammonia levels?
A. Furosemide
B. Lactulose
C. Propranolol
D. Spironolactone
Answer: B. Lactulose
Rationale: Lactulose binds ammonia in the gut, reducing systemic levels and improving hepatic encephalopathy. Diuretics are for fluid overload, not ammonia.
Which interventions reduce risk of central line-associated bloodstream infection? (Select all that apply.)
A. Daily chlorhexidine baths
B. Sterile dressing changes
C. Routine antibiotic prophylaxis
D. Hand hygiene
E. Scrub the hub
Answer: A, B, D, E
Rationale: CLABSI prevention relies on aseptic technique, hand hygiene, hub scrubbing, and chlorhexidine. Routine antibiotics are not recommended due to resistance risk.
A client is receiving IV furosemide for fluid overload. Which interventions are appropriate? (Select all that apply.)
A. Monitor serum potassium
B. Encourage potassium-rich foods
C. Daily weights
D. Monitor urine output
E. Restrict sodium intake
Answer: A, B, C, D, E
Rationale: Loop diuretics can cause potassium loss and volume depletion. All listed interventions support electrolyte and fluid balance.
A client with hyperthyroidism is at risk for which complications? (Select all that apply.)
A. Tachycardia
B. Heat intolerance
C. Weight gain
D. Diarrhea
E. Hypertension
Answer: A, B, D, E
Rationale: Hyperthyroidism increases metabolism, causing tachycardia, hypertension, heat intolerance, and diarrhea. Weight loss—not gain—is typical.
A client received alteplase for ischemic stroke. Which findings require immediate reporting? (Select all that apply.)
A. Oozing at IV site
B. Sudden severe headache
C. New confusion
D. BP 138/84
E. Hematuria
Answer: A, B, C, E
Rationale: Signs of bleeding or neurological change are critical complications of thrombolytic therapy. Normal BP is expected; minor changes are less urgent.
Which ABG pattern is expected in chronic COPD?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis
Answer: C. Respiratory acidosis
Rationale: Chronic CO2 retention in COPD causes compensated respiratory acidosis with high PaCO2 and possible metabolic compensation over time.
Which task can the RN delegate to unlicensed assistive personnel (UAP)?
A. Assess lung sounds
B. Administer IV antibiotics
C. Obtain vital signs on stable client
D. Teach about insulin administration
Answer: C. Obtain vital signs on stable client
Rationale: UAPs can perform routine data collection on stable clients. Assessment, medication administration, and patient teaching are RN-only responsibilities.
A client with cirrhosis has ascites and 4+ pitting edema. Which intervention is the priority?
A. Encourage ambulation
B. Administer spironolactone
C. Perform daily weight
D. Assess for hepatic encephalopathy
Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic used to remove excess fluid and prevent further complications. Assessment and weights follow but diuresis is priority.
A client presents with fatigue, weight gain, dry skin, and bradycardia. Which lab finding confirms the suspected diagnosis?
A. Low TSH, high T4
B. High TSH, low T4
C. Low TSH, low T4
D. High TSH, high T4
Answer: B
Rationale: Primary hypothyroidism shows high TSH due to lack of negative feedback and low T4 due to decreased thyroid hormone production.