Category 1
A client with Addison’s disease presents with hypotension, hyperpigmentation, and hyponatremia. Which is the priority nursing action?
A. Administer IV hydrocortisone
B. Encourage oral fluids
C. Check blood glucose
D. Apply sunscreen
Answer: A
Rationale: Adrenal crisis is life-threatening. IV corticosteroids replace deficient cortisol and stabilize BP.
A client with hypercalcemia from malignancy is at risk for:
A. Constipation
B. Hypotension
C. Seizures
D. Diarrhea
Answer: A
Rationale: Hypercalcemia decreases GI motility, leading to constipation, nausea, and abdominal discomfort.
A client presents with atrial fibrillation with a heart rate of 160 bpm. Which is the priority nursing action?
A. Administer digoxin as prescribed
B. Prepare for synchronized cardioversion
C. Assess for chest pain and hypotension
D. Call for a 12-lead ECG
Answer: C
Rationale: Priority is assessing hemodynamic stability. If the client is unstable (hypotension, chest pain, syncope), immediate intervention (cardioversion) may be needed.
A client presents with left-sided hemiplegia, facial droop, and slurred speech. The stroke is ischemic. What is the next action?
A. Administer tPA if within the window
B. Perform complete neuro exam
C. Elevate the head of bed
D. Administer aspirin
Answer: A
Rationale: Time-sensitive thrombolytic therapy for ischemic stroke is highest priority. Neuro assessment follows.
Which interventions protect nurses from chemotherapy exposure? (Select all that apply.)
A. Wear double gloves
B. Use gown and eye protection
C. Handle oral chemo like regular meds
D. Dispose of IV tubing in chemo waste
E. Wash hands after administration
Answer: A, B, D, E
Rationale: Proper PPE and safe handling prevent exposure. Oral chemo still requires caution.
A client with primary hyperaldosteronism may exhibit which findings? (Select all that apply.)
A. Hypertension
B. Hypokalemia
C. Hypernatremia
D. Weight loss
E. Muscle weakness
Answer: A, B, C, E
Rationale: Excess aldosterone causes sodium retention (hypernatremia), potassium loss (hypokalemia), hypertension, and muscle weakness. Weight loss is not typical.
Which findings are consistent with hypokalemia? (Select all that apply.)
A. Muscle weakness
B. Flat T waves on ECG
C. Polyuria
D. Constipation
E. Hyperreflexia
Answer: A, B, C, D
Rationale: Hypokalemia causes muscle weakness, ECG changes, polyuria, and constipation. Hyperreflexia is more associated with hyperkalemia.
A client with chronic heart failure is being discharged. Which instructions should the nurse include? (Select all that apply.)
A. Daily weights
B. Restrict sodium intake
C. Monitor for swelling in ankles
D. Avoid all physical activity
E. Take medications as prescribed
Answer: A, B, C, E
Rationale: Monitoring weight, sodium, edema, and medication adherence is essential. Physical activity is encouraged as tolerated.
Which are early signs of increased intracranial pressure? (Select all that apply.)
A. Headache
B. Vomiting
C. Pupillary changes
D. Hypertension with bradycardia
E. Confusion
Answer: A, B, E
Rationale: Early ICP changes include headache, vomiting, and mental status changes. Cushing’s triad (D) is a late sign.
A client with terminal cancer reports severe pain not relieved by current medications. What is the priority nursing action?
A.Document current medication effectiveness
B. Notify provider for opioid adjustment
C. Encourage distraction techniques
D. Assess pain using validated scale
Answer: D
Rationale: Pain assessment is the first step to determine appropriate interventions.
A client with SIADH is at risk for:
A. Hypernatremia
B. Hyponatremia
C. Hyperkalemia
D. Hypokalemia
Answer: B
Rationale: SIADH causes water retention, diluting sodium levels, leading to hyponatremia.
A client has serum magnesium of 3.2 mEq/L. Which is the priority action?
A. Administer calcium gluconate
B. Give magnesium supplement
C. Encourage oral magnesium intake
D. Restrict fluids
Answer: A
Rationale: Hypermagnesemia can cause cardiac conduction issues. Calcium gluconate antagonizes magnesium and stabilizes the heart.
A client with asthma presents with wheezing, tachypnea, and oxygen saturation of 88%. What is the priority action?
A. Administer albuterol via nebulizer
B. Place on low-flow oxygen
C. Obtain arterial blood gas
D. Encourage deep breathing
Answer: A
Rationale: Immediate bronchodilation is priority to relieve airway obstruction and improve oxygenation. Oxygen and ABGs follow.
Which intervention can be safely delegated to UAP during a seizure?
A. Administer IV lorazepam
B. Record duration and characteristics
C. Insert airway
D. Obtain ABG
Answer: B
Rationale: UAP can record seizure activity. All other tasks are nursing responsibilities.
Which interventions improve comfort for a client with advanced cancer? (Select all that apply.)
A. Reposition frequently
B. Administer PRN pain meds
C. Encourage aggressive chemotherapy
D. Use non-pharmacologic measures (music, massage)
E. Provide emotional support
Answer: A, B, D, E
Rationale: Comfort measures, pharmacologic and non-pharmacologic, plus emotional support improve quality of life. Aggressive chemo may not be indicated.
A client with type 1 diabetes presents with diaphoresis, confusion, and tremors. Which action should the nurse take first?
A. Administer 50 mL D50 IV
B. Check vital signs
C. Notify provider
D. Administer insulin
Answer: A
Rationale: Symptoms indicate hypoglycemia, which is immediately life-threatening. Rapid glucose replacement is priority.
A client receiving TPN develops muscle weakness and confusion. Which lab result confirms hypophosphatemia?
A. Phosphate 3.0 mg/dL
B. Phosphate 4.0 mg/dL
C. Phosphate 5.2 mg/dL
D. Phosphate 1.8 mg/dL
Answer: D
Rationale: Normal phosphate = 2.5–4.5 mg/dL. 1.8 indicates hypophosphatemia, causing neuromuscular symptoms.
A client with COPD has increased sputum, dyspnea, and wheezing. Which actions are appropriate? (Select all that apply.)
A. Administer prescribed bronchodilators
B. Encourage fluid intake
C. Monitor oxygen saturation
D. Provide high-flow oxygen continuously
E. Teach pursed-lip breathing
.
Answer: A, B, C, E
Rationale: Bronchodilators, hydration, monitoring, and breathing techniques improve airflow and prevent CO₂ retention. High-flow oxygen must be used cautiously
A client with Parkinson’s disease is prescribed carbidopa-levodopa. When is the best time to administer?
A. With meals
B. 30 minutes before meals
C. At bedtime
D. Only as needed for tremor
Answer: B
Rationale: Giving before meals improves absorption and decreases competition with protein for uptake.
A client’s ABG shows: pH 7.48, PaCO₂ 30 mmHg, HCO₃⁻ 24 mEq/L. Which is the correct interpretation?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
Answer: B
Rationale: High pH and low PaCO₂ indicate respiratory alkalosis, likely due to hyperventilation.
A client has ABG results: pH 7.30, PaCO₂ 50 mmHg, HCO₃⁻ 24 mEq/L. Which interventions are appropriate? (Select all that apply.)
A. Encourage deep breathing
B. Administer sodium bicarbonate
C. Assess oxygen saturation
D. Monitor heart rhythm
E. Restrict fluids
Answer: A, C, D
Rationale: ABG shows respiratory acidosis (high CO₂). Encourage ventilation, monitor oxygen and cardiac rhythm. Bicarbonate is not first-line; fluids are not indicated.
A client with COPD presents with ABG: pH 7.33, PaCO₂ 55 mmHg, HCO₃⁻ 30 mEq/L. Which nursing actions are appropriate? (Select all that apply.)
A. Monitor oxygen saturation
B. Encourage pursed-lip breathing
C. Administer high-flow oxygen to maintain PaO₂ >100
D. Monitor for signs of respiratory fatigue
E. Assess mental status
Answer: A, B, D, E
Rationale: ABG shows compensated respiratory acidosis. High-flow O₂ may suppress hypoxic drive in chronic COPD. Monitoring, breathing techniques, and mental status are priorities.
A client with ARDS is on mechanical ventilation. Which finding requires immediate intervention?
A. Oxygen saturation drops from 92% → 84%
B. Blood pressure is 130/80 mmHg
C. Heart rate is 98 bpm
D. Lung sounds are coarse bilaterally
Answer: A
Rationale: Sudden hypoxemia indicates ventilator/oxygenation problem and requires rapid intervention.
Which is a priority nursing intervention during an acute MS exacerbation?
A. Administer high-dose corticosteroids
B. Encourage ambulation
C. Begin physical therapy
D. Provide dietary counseling
Answer: A
Rationale: Corticosteroids reduce inflammation and decrease duration/severity of flare.
A client post-op has O₂ saturation of 88% on room air. Which actions are appropriate? (Select all that apply.)
A. Apply supplemental oxygen
B. Raise head of bed
C. Encourage deep breathing/coughing
D. Call rapid response immediately
E. Encourage bedrest
Answer: A, B, C
Rationale: Hypoxia requires oxygen, positioning, and lung expansion. Bedrest is not therapeutic; RRT may be considered if deterioration continues.