Category 1
A client’s ECG shows ST elevation in leads V1–V4. Which type of MI is this?
A. Inferior MI
B. Lateral MI
C. Anterior MI
D. Posterior MI
Answer: C
Rationale: Leads V1–V4 correspond to the anterior wall, typically supplied by the left anterior descending artery.
A client with chronic kidney disease (CKD) has a potassium level of 6.2 mEq/L. Which is the priority nursing action?
A. Administer sodium polystyrene sulfonate (Kayexalate) as prescribed
B. Place the client on a low-potassium diet
C. Notify the provider immediately
D. Recheck potassium in 6 hours
Answer: C
Rationale: Hyperkalemia >6 mEq/L is life-threatening due to risk of arrhythmia. Immediate provider notification is required for urgent intervention
A client with cirrhosis presents with confusion, asterixis, and ammonia level of 120 µmol/L. Which medication should the nurse anticipate administering?
A. Spironolactone
B. Furosemide
C. Lactulose
D. Metoclopramide
Answer: C
Rationale: Lactulose reduces ammonia levels, improving hepatic encephalopathy symptoms.
Which are common complications of pancreatitis? (Select all that apply.)
A. Hypocalcemia
B. Hyperglycemia
C. Pancreatic pseudocyst
D. Pleural effusion
E. Hypernatremia
Answer: A, B, C, D
Rationale: Pancreatitis can cause electrolyte disturbances, pseudocysts, and pleural effusions. Sodium imbalance is less typical.
A client with vomiting and diarrhea has labs: Na⁺ 130 mEq/L, K⁺ 2.9 mEq/L. Which is the priority action?
A. Monitor vitals
B. Encourage oral fluids
C. Administer antiemetic PRN
D. Start IV potassium replacement
Answer: D
Rationale: Severe hypokalemia is life-threatening and must be corrected first.
A client with suspected ACS is receiving the MONA protocol. Which actions are correct? (Select all that apply.)
A. Administer oxygen if <90%
B. Give sublingual nitroglycerin
C. Give chewable aspirin
D. Administer IV morphine
E. Withhold beta-blockers if HR <60
Answer: A, B, C, D, E
Rationale: MONA-B protocol includes oxygen, nitrates, aspirin, morphine, and careful use of beta-blockers.
Which are common complications of CKD? (Select all that apply.)
A. Anemia
B. Hyperkalemia
C. Hypocalcemia
D. Fluid overload
E. Hypernatremia
Answer: A, B, C, D
Rationale: CKD causes anemia, electrolyte imbalances (high K⁺, low Ca²⁺), and fluid overload. Sodium is usually normal or slightly elevated.
Which are potential complications of cirrhosis? (Select all that apply.)
A. Ascites
B. Esophageal varices
C. Portal hypertension
D. Hyperglycemia
E. Spontaneous bacterial peritonitis
Answer: A, B, C, E
Rationale: Cirrhosis can cause fluid overload (ascites), varices, portal hypertension, and infection. Hyperglycemia is less directly related.
A client with pancreatitis has the following labs: Amylase 450 U/L, Lipase 900 U/L, WBC 14. What is the priority nursing action?
A. Start IV antibiotics
B. Monitor for signs of sepsis
C. Administer pain medication PRN
D. Encourage oral intake
Answer: B
Rationale: Elevated WBC with high pancreatic enzymes may indicate infection or necrosis. Close monitoring is crucial.
Which post-op instructions are appropriate after laparoscopic cholecystectomy? (Select all that apply.)
A. Avoid heavy lifting for 1–2 weeks
B. Take low-fat diet indefinitely
C. Monitor incision for signs of infection
D. Resume normal activities immediately
E. Report persistent jaundice or dark urine
Answer: A, B, C, E
Rationale: Gradual activity, diet modification, incision monitoring, and watching for complications are standard.
53. (MC – Priority / Delegation)
Which task should the RN perform personally rather than delegate?
A. Monitor urine output on stable post-op client
B. Teach insulin administration to newly diagnosed diabetes
C. Assist with ambulation
D. Obtain vital signs
Answer: B
Rationale: Teaching requires RN knowledge and assessment of understanding. Other tasks can be delegated.
A client with acute kidney injury has urine output of 25 mL over the last 2 hours and BP 85/50 mmHg. Which is the priority intervention?
A. Obtain urinalysis.
B. Restrict potassium intake
C. Prepare for dialysis
D. Administer IV fluids
Answer: D
Rationale: Hypotension with oliguria indicates prerenal AKI. Restoring perfusion with IV fluids is first priority.
A client presents with RUQ pain, fever, and jaundice. Murphy’s sign is positive. What is the priority intervention?
A. Prepare for cholecystectomy
B. Apply warm compress to abdomen
C. Teach low-fat diet
D. Administer broad-spectrum antibiotics
Answer:D
Rationale: Acute cholecystitis with infection requires immediate antibiotics to prevent sepsis. Surgery may follow stabilization.
A client on hemodialysis presents with muscle cramps, hypotension, and K⁺ 3.2 mEq/L. Which is the priority intervention?
A. Administer IV fluids
B. Administer potassium supplement
C. Hold next dialysis session
D. Notify provider
Answer: B
Rationale: Hypokalemia can cause arrhythmias and muscle weakness. Rapid replacement is needed.
A client with severe pancreatitis reports 9/10 abdominal pain. Which is the priority action?
A. Administer IV morphine
B. Encourage deep breathing
C. Apply warm compress
D. Administer sodium polystyrene
Answer: A
Rationale: Severe pain requires immediate IV analgesia. Non-pharmacologic measures are adjuncts.
A client with pneumonia has new confusion, O₂ sat 86%, and BP 80/50 mmHg. Which is the first action?
A. Administer IV fluids
B. Apply supplemental oxygen
C. Obtain sputum culture
D. Administer antibiotics
Answer: B
Rationale: Hypoxia is immediately life-threatening; oxygenation comes first, then fluid resuscitation and antibiotics.
A client receiving hemodialysis develops sudden chest pain, dyspnea, and hypotension. What is the priority action?
A. Document the episode
B. Administer prescribed antihypertensive
C. Reposition supine and elevate legs
D. Stop dialysis and notify the provider
Answer: D
Rationale: Sudden hypotension and chest pain indicate dialysis-related complication (air embolism, hypotension). Stop dialysis immediately.
Which findings are associated with acute cholecystitis? (Select all that apply.)
A. RUQ pain radiating to right shoulder
B. Fever and leukocytosis
C. Positive Murphy's sign
D. Hematuria
E. Nausea and vomiting
Answer: A, B, C, E
Rationale: RUQ pain, fever, positive Murphy's sign, and GI upset are classic signs. Hematuria is unrelated.
Which are priority actions for a client undergoing peritoneal dialysis? (Select all that apply.)
A. Monitor for cloudy effluent
B. Keep catheter site sterile
C. Encourage ambulation immediately post-dialysis
D. Record input and output accurately
E. Warm dialysate before infusion
Answer: A, B, D, E
Rationale: Preventing infection and monitoring fluid balance is essential. Ambulation is limited initially.
Which medication is contraindicated in a client with CKD and hyperkalemia?
A. Furosemide
B. Lisinopril
C. Calcium carbonate
D. Erythropoietin
Answer: B
Rationale: ACE inhibitors (like lisinopril) increase potassium, worsening hyperkalemia.
Which factors increase risk for ischemic stroke? (Select all that apply.)
A. Hypertension
B. Diabetes
C. Atrial fibrillation
D. Smoking
E. Hypotension
Answer: A, B, C, D
Rationale: Stroke risk is increased by HTN, DM, AFib, and smoking. Hypotension is not a primary risk factor.
A 64-year-old female with end-stage renal disease (ESRD) on hemodialysis presents to the clinic with complaints of muscle cramps and itching. Laboratory results reveal:
Phosphorus: 6.8 mg/dL (elevated)
Calcium: 7.9 mg/dL (low)
Creatinine: elevated
PTH: elevated
The provider diagnoses hyperphosphatemia related to chronic kidney disease.
Which intervention should the nurse prioritize in managing this patient’s condition?
A. Administer IV calcium gluconate immediately
B. Encourage increased intake of dairy products
C. Administer Sevelamer with meals
D. Restrict potassium-rich foods
Correct Answer: C. Administer Sevelamer with meals. Rationale: In chronic kidney disease, the kidneys cannot excrete phosphorus effectively, leading to:
Hyperphosphatemia
Hypocalcemia (phosphorus binds calcium)
Secondary hyperparathyroidism
Bone demineralization
Pruritus
Phosphate binders (such as calcium acetate or sevelamer) are given with meals to:
Bind dietary phosphorus in the gut
Prevent absorption
Lower serum phosphate levels
Why the Other Options Are Incorrect:
A. IV calcium gluconate
Used for symptomatic hypocalcemia or cardiac instability — not routine phosphate control.
B. Increase dairy
Dairy is high in phosphorus and would worsen the problem.
D. Restrict potassium
Important in CKD, but does not address hyperphosphatemia.
A client with acute pancreatitis has severe abdominal pain, hypotension, and tachycardia. Which is the priority nursing action?
A. Apply warm compress to abdomen
B. Give oral pancreatic enzymes
C. Administer IV fluids rapidly
D. Encourage ambulation
Answer: C
Rationale: Hypotension and tachycardia indicate hypovolemia and shock. Aggressive fluid resuscitation is priority.
Which intervention is priority for a client with massive ascites?
A. Administer Sevelamer
B. Encourage oral fluids
C. Administer IV albumin
D. Place in supine position
Answer: C
Rationale: Albumin helps maintain oncotic pressure and prevents hypotension during fluid shifts.
A client with CKD and ascites reports confusion, decreased urine output, and low BP. Which actions are priority? (Select all that apply.)
A. Assess vital signs and level of consciousness
B. Notify provider immediately
C. Administer prescribed diuretic
D. Prepare for IV fluid resuscitation
E. Document findings
Answer: A, B, D
Rationale: Hypotension, confusion, and oliguria indicate shock/AKI. Immediate assessment and provider notification are priority; diuretics could worsen hypotension.