Category 1
A client presents with blood glucose 520 mg/dL, Kussmaul respirations, fruity breath, and nausea. Which is the priority nursing action?
A. Administer subcutaneous insulin
B. Start IV fluids
C. Encourage oral fluids
D. Monitor blood glucose every 4 hours
Answer: B. Start IV fluids
Rationale:
The first priority in DKA is fluid resuscitation to correct dehydration, improve perfusion, and restore electrolyte balance. IV insulin is important but after initiating fluids, because giving insulin first can worsen hypovolemia and hypotension. Oral fluids are insufficient due to nausea and altered mental status. Monitoring glucose every 4 hours alone is not an intervention; it is part of ongoing assessment.
A client with Cushing’s syndrome develops a BP of 180/100, moon face, and purple striae. Which lab finding is expected?
A. Hyperkalemia
B. Hypoglycemia
C. Hypernatremia
D. Low cortisol
Answer: C
Rationale: Excess cortisol causes hypernatremia, hypertension, hyperglycemia, and potassium loss.
A client with multiple chronic conditions takes 12 medications. Which nursing action is priority?
A. Review for potential drug-drug interactions
B. Encourage client to take meds with meals
C. Administer meds on schedule
D. Assess vital signs
Answer: A
Rationale: Polypharmacy increases risk for adverse interactions, which can be life-threatening.
A client’s ECG shows: PR interval 0.24 sec, regular rhythm, rate 58. What is the interpretation?
A. Normal sinus rhythm
B. First-degree AV block
C. Sinus bradycardia
D. Second-degree AV block
Answer: B
Rationale: PR >0.20 sec with regular rhythm and normal rate is first-degree AV block.
A client has a new order for IV potassium 40 mEq in 1000 mL NS over 4 hours. What is priority nursing action?
A. Infuse via peripheral IV
B. Verify cardiac monitoring is in place
C. Administer as IV push
D. Dilute in 250 mL NS
Answer: B
Rationale: High-dose IV K⁺ can cause fatal arrhythmias. Continuous cardiac monitoring is mandatory.
Which findings are consistent with hyperosmolar hyperglycemic state (HHS)? (Select all that apply.)
A. Blood glucose >600 mg/dL
B. Ketones in urine
C. Severe dehydration
D. Altered mental status
E. Kussmaul respirations
Answer: A, C, D
Rationale: HHS involves extreme hyperglycemia, dehydration, and neurologic changes. Ketones and Kussmaul respirations are more typical of DKA.
A client has serum sodium 122 mEq/L, confusion, and low urine output. Which is the priority action?
A. Restrict fluids
B. Administer hypotonic IV fluids
C. Encourage oral fluids
D. Administer diuretics
Answer: A
Rationale: SIADH causes water retention and hyponatremia. Fluid restriction is first-line to prevent neurologic complications.
A client is prescribed IV vancomycin. Which lab should be monitored prior to administration?
A. Sodium
B. Creatinine
C. Potassium
D. Glucose
Answer: B
Rationale: Vancomycin is nephrotoxic. Creatinine ensures safe kidney function before dosing.
Which findings are priority in a client with hyperkalemia? (Select all that apply.)
A. Peaked T waves
B. Muscle weakness
C. Hypotension
D. Nausea
E. Shortness of breath
Answer: A, B, C, E
Rationale: Cardiac conduction changes, weakness, hypotension, and dyspnea indicate life-threatening hyperkalemia.
ABG: pH 7.50, PaCO₂ 30, HCO₃ 24. Interpretation?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
Answer: B
Rationale: High pH + low PaCO₂ indicates primary respiratory alkalosis.
A client with Graves’ disease reports palpitations, heat intolerance, and tremors. Which medication is most likely prescribed?
A. Levothyroxine
B. Methimazole
C. Hydrocortisone
D. Insulin
Answer: B
Rationale: Methimazole blocks thyroid hormone synthesis, treating hyperthyroidism.
Which are important precautions when caring for a client receiving chemotherapy? (Select all that apply.)
A. Use PPE when handling bodily fluids
B. Encourage high-potassium diet
C. Monitor for neutropenia
D. Avoid live vaccines
E. Maintain strict hand hygiene
Answer: A, C, D, E
Rationale: Chemotherapy increases infection risk; PPE and hygiene prevent exposure. Live vaccines are contraindicated.
Which tasks can the RN delegate to UAP for stable clients? (Select all that apply.)
A. Obtain vital signs
B. Assist with ambulation
C. Administer oral medications
D. Measure intake and output
E. Apply sterile dressings
Answer: A, B, D
Rationale: UAPs can perform routine supportive tasks. Medication administration and sterile procedures require RN.
A post-op client has sudden shortness of breath, tachycardia, and O₂ 85%. Which is priority?
A. Apply oxygen
B. Notify provider
C. Assess lung sounds
D. Elevate head of bed
Answer: D
Rationale: Elevating head improves oxygenation immediately; subsequent assessment and provider notification follow.
A client with heart failure (HF) and chronic kidney disease (CKD) reports edema, fatigue, and a 4-lb weight gain over 2 days. Which nursing action is the top priority?
A. Document findings
B. Notify the provider
C. Administer IV diuretics
D. Restrict sodium intake
E. Assess vital signs
Rationale:
The client is showing signs of acute fluid overload, which can quickly progress to pulmonary edema, respiratory distress, or worsening cardiac output.
IV diuretics act rapidly to remove excess fluid, stabilizing the client physiologically, which is the top priority in acute care.
While notifying the provider, assessing vitals, restricting sodium, and documenting are all important, they are secondary to relieving the immediate risk caused by fluid overload.
Prioritization in Med-Surg focuses first on physiologic threats to life, then interventions and reporting.
Which interventions are appropriate after thyroidectomy? (Select all that apply.)
A. Monitor for signs of hypocalcemia
B. Assess for airway obstruction
C. Encourage immediate neck flexion exercises
D. Check voice for hoarseness
E. Provide high-calcium diet
Answer: A, B, D, E
Rationale: Post-thyroidectomy complications include airway compromise, hypocalcemia (parathyroid injury), and vocal cord issues. Neck flexion exercises are avoided initially.
A client with terminal cancer reports 9/10 pain. Which is the priority nursing action?
A. Administer prescribed opioid
B. Encourage distraction techniques
C. Assess vital signs
D. Wait 30 minutes and reassess
Answer: A
Rationale: Pain relief is primary goal in palliative care. Opioids are first-line for severe pain.
A client with CHF has BP 90/50, HR 128, O₂ 88%, and new confusion. Who should the nurse see first?
A. Client with chest pain and normal vitals
B. Client above (CHF)
C. Post-op client requesting pain meds
D. Stable diabetes client for insulin
Answer: B
Rationale: Hypotension, hypoxia, tachycardia, and confusion indicate immediate risk of organ hypoperfusion.
Mr. J, a 58-year-old patient with cirrhosis, is admitted with increasing confusion, lethargy, and asterixis. Lab results show ammonia 150 µmol/L. The patient’s diet is currently low-protein, and he has mild ascites.
Question:
Which medication does the nurse anticipate administering along with lactulose to manage his hepatic encephalopathy?
A. Metoclopramide
B. Furosemide
C. Spironolactone
D. Rifaximin
Answer: D. Rifaximin
Rationale:
Lactulose is used to lower ammonia levels by trapping ammonia in the gut and promoting excretion. Rifaximin, a non-absorbable antibiotic, is often given in combination with lactulose to reduce ammonia-producing gut bacteria, further preventing hepatic encephalopathy.
Which client should the nurse see first?
A. Post-MI client with chest pain 4/10
B. Post-op client with BP 128/72,
C. CKD client with K⁺ 6.5 and peaked T waves
D. Diabetes client with BG 190
Answer: C
Rationale: Hyperkalemia with peaked T waves is life-threatening. Immediate intervention is priority.
A client with Addison’s disease presents with hypotension, hyponatremia, and hyperkalemia. Which is the priority intervention?
A. Administer IV hydrocortisone
B. Encourage oral sodium intake
C. Monitor vital signs every 8 hours
D. Restrict potassium
Answer: A
Rationale: Addisonian crisis is life-threatening. IV corticosteroids restore hemodynamic stability.
Which signs indicate approaching end of life? (Select all that apply.)
A. Decreased appetite and intake
B. Cheyne-Stokes respirations
C. Cool extremities
D. Increased urinary output
E. Mottling of skin
Answer: A, B, C, E
Rationale: Decreased intake, irregular breathing, poor perfusion, and skin mottling are common end-of-life changes.
ABG results: pH 7.25, PaCO₂ 52, HCO₃ 24. Which acid-base imbalance is present?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: B
Rationale: Low pH + high PaCO₂ indicates primary respiratory acidosis. HCO₃ is normal → no metabolic compensation yet.
Which assessments are priority for a client receiving chemotherapy? (Select all that apply.)
A. Neutrophil count
B. Oral mucosa inspection
C. Vital signs
D. Bowel sounds
E. Weight
Answer: A, B, C, E
Rationale: Neutropenia and mucositis increase infection risk; vital signs and weight monitor overall status.
A client with cirrhosis and hepatic encephalopathy is admitted with confusion, asterixis, and ammonia level of 140 µmol/L. The client enjoys high-protein foods and asks if they can continue their usual diet. What should the nurse anticipate regarding protein intake?
A. Encourage high-protein foods to prevent malnutrition
B. Restrict protein completely until ammonia levels normalize
C. Provide moderate protein, focusing on vegetable and dairy sources
D. Allow unlimited protein as long as lactulose is administered
C. Provide moderate protein, focusing on vegetable and dairy sources ✅
Rationale:
Excess protein can increase ammonia production in clients with hepatic encephalopathy, worsening confusion and neurologic status.
Complete protein restriction is no longer recommended, as prolonged restriction can cause malnutrition and muscle wasting, which worsen outcomes.
Moderate protein intake (often 1.2–1.5 g/kg/day) with vegetable and dairy sources is safest; these are less likely to increase ammonia.
Lactulose and rifaximin are used concurrently to reduce ammonia levels, but dietary protein should still be moderated, not eliminated.