Saftey/Falls
A client with sudden confusion is found in bed with a temperature of 103.2°F (39.6°C), diaphoresis, and no identification. Which action should the nurse take first?
Multiple-Choice:
(A) Initiate safety measures and obtain a focused assessment of vital signs and neurologic status
(B) Ask family members for baseline memory status
(C) Offer oral fluids and encourage rest
(D) Complete a full mental status examination before any other action
Correct Answer: (A) Initiate safety measures and obtain a focused assessment of vital signs and neurologic status
Rationale: Safety comes first because the client is confused and at high risk for harm, and the fever suggests an urgent medical problem. The nurse should immediately ensure safety and assess vital signs and neurologic status to identify possible delirium or another acute cause. Family history is helpful but not the first action. Oral fluids may be appropriate later, but the priority is immediate assessment and safety. A full mental status examination is important, but not before stabilizing safety concerns and obtaining urgent data.
The nurse is caring for a client with fluid volume deficit from gastroenteritis. Which data should the nurse report to the provider immediately?
Multiple-Choice:
(A) Heart rate 128/min with a weak radial pulse
(B) Reports mild thirst after walking
(C) Urine output 40 mL over the past hour
(D) Dry lips and requesting ice chips
Correct Answer: (A) Heart rate 128/min with a weak radial pulse
Rationale: Marked tachycardia with a weak pulse suggests worsening volume depletion and possible hemodynamic compromise, requiring immediate reporting. Mild thirst after activity is expected and less urgent. Urine output of 40 mL/hour is generally acceptable in many adults. Dry lips and a request for ice chips are expected findings and do not require immediate escalation.
The nurse is caring for a postoperative patient 24 hours after abdominal surgery. Which findings may indicate the patient is developing a postoperative complication? Select all that apply.
A. Temperature 101.8°F (38.8°C)
B. Productive cough with crackles
C. Oxygen saturation 88%
D. Hypoactive bowel sounds immediately after surgery
E. Sudden decrease in hemoglobin level
F. Calf pain and unilateral swelling
Correct Answers: A, B, C, E, F
Rationales
The nurse is caring for a patient receiving IV potassium chloride for hypokalemia. Which finding requires the nurse’s immediate intervention?
A. Potassium infusion running on an infusion pump
B. Patient reports mild burning at IV site
C. IV potassium being administered by IV push
D. Cardiac monitor in place during infusion
Correct Answer: C — IV potassium being administered by IV push
Rationales
The nurse is caring for a patient with diabetes who suddenly becomes shaky, sweaty, and confused. The patient’s blood glucose is 58 mg/dL.
What should the nurse do first?
A. Administer insulin
B. Give orange juice
C. Call the healthcare provider
D. Reassess blood glucose in 1 hour
Correct Answer: B — Give orange juice
Rationales
A patient with sundowning becomes more confused at night. Which intervention is most appropriate?
A. Limit supervision
B. Increase stimulation
C. Provide more supervision and reorientation
D. Keep patient isolated
Question 1: A client with heart failure has gained 2.4 kg in 2 days, has crackles at the lung bases, and has jugular vein distention. Which action should the nurse take first?
Multiple-Choice:
(A) Elevate the legs and encourage ambulation
(B) Notify the provider and prepare to administer prescribed diuretics
(C) Encourage increased oral fluids to support circulation
(D) Place the client in Trendelenburg position
Correct Answer: (B) Notify the provider and prepare to administer prescribed diuretics
Rationale: The findings suggest fluid volume excess with pulmonary congestion. The nurse should escalate the change in status and anticipate diuretic therapy to reduce volume overload. Elevating the legs may worsen venous return and does not treat the cause. Increasing fluids would worsen overload. Trendelenburg positioning is inappropriate and can impair breathing.
The nurse is assessing a patient for risk factors that increase the likelihood of postoperative complications. Which findings increase the patient’s surgical risk? Select all that apply.
A. Obesity
B. Smoking history
C. Diabetes mellitus
D. Age 22 years old
E. Hypertension
F. Adequate nutrition
Rationales
The nurse is preparing morning medications for a patient with difficulty swallowing. One medication is prescribed as extended-release oxycodone (ER).
Which action by the nurse is most appropriate?
A. Crush the medication and mix it with applesauce
B. Split the tablet in half before administration
C. Administer the medication whole as prescribed
D. Dissolve the tablet in water before giving
Cultural Assessment Question
A nurse is completing an admission assessment for a newly hospitalized patient from a different cultural background. The nurse wants to provide culturally competent care.
Which nursing actions are appropriate? (Select all that apply)
A. Ask the patient about cultural beliefs that may affect health care decisions
B. Assume the patient follows common practices of their ethnic group
C. Ask if the patient has any dietary or religious restrictions
D. Avoid discussing culture to prevent offending the patient
E. Use open-ended questions to explore health beliefs and practices
F. Document cultural preferences in the care plan
orrect Answers: A, C, E, F
✔ A. Ask the patient about cultural beliefs that may affect health care decisions
Rationale (Correct):
Why others are wrong:
❌ B. Assume the patient follows common practices of their ethnic group
Rationale (Incorrect):
✔ C. Ask if the patient has any dietary or religious restrictions
Rationale (Correct):
❌ D. Avoid discussing culture to prevent offending the patient
Rationale (Incorrect):
✔ E. Use open-ended questions to explore health beliefs and practices
Rationale (Correct):
✔ F. Document cultural preferences in the care plan
Rationale (Correct):
The nurse is caring for four patients on a medical-surgical unit. Which task is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
Which principle should the nurse follow when delegating to a UAP?
A. Delegate unstable patients to reduce workload
B. Delegate assessment and teaching tasks
C. Delegate routine, stable, predictable tasks
D. Delegate nursing judgment tasks when busy
client with hypernatremia is receiving hypotonic IV fluids. Which finding requires immediate follow-up?
Multiple-Choice:
(A) New onset of confusion and seizures
(B) Serum sodium decreased from 156 to 154 mEq/L
(C) Urine output of 40 mL/hr
(D) Thirst has decreased
Correct Answer: (A) New onset of confusion and seizures
Rationale: Rapid lowering of serum sodium can cause cerebral edema, which may present with confusion, seizures, and neurologic decline. A small sodium decrease is expected with treatment. Urine output of 40 mL/hr is acceptable. Decreased thirst can indicate improvement.
The nurse suspects a patient is experiencing fluid volume excess after surgery. Which findings support this assessment? Select all that apply.
A. Crackles in lungs
B. Peripheral edema
C. Shortness of breath
D. Flat neck veins
E. Elevated blood pressure
F. Dry mucous membranes
A nurse is assessing an 86-year-old patient who is admitted with confusion and weakness. The patient reports taking “many medications at home,” but cannot recall all of them. The patient also states, “I drink a glass of wine every night.”
Which nursing actions are appropriate? (Select all that apply)
A. Ask the patient to bring in all home medications or a medication list
B. Assess the patient’s alcohol use and frequency
C. Assume confusion is related only to aging and document as expected
D. Perform a complete medication reconciliation with pharmacy records if available
E. Ask about over-the-counter (OTC) medications and herbal supplements
F. Immediately discontinue all home medications without provider order
Correct Answers: A, B, D, E
✔ A. Ask the patient to bring in all home medications or a medication list
Rationale (Correct):
✔ B. Assess the patient’s alcohol use and frequency
Rationale (Correct):
❌ C. Assume confusion is related only to aging and document as expected
Rationale (Incorrect):
✔ D. Perform a complete medication reconciliation with pharmacy records if available
Rationale (Correct):
✔ E. Ask about over-the-counter (OTC) medications and herbal supplements
Rationale (Correct):
❌ F. Immediately discontinue all home medications without provider order
Rationale (Incorrect):
A nurse is caring for a 90-year-old patient admitted from home. The patient has unexplained weight loss, appears dehydrated, and has a caregiver who repeatedly answers questions for the patient. The patient avoids eye contact and becomes quiet when the caregiver enters the room.
Which nursing actions are appropriate? (Select all that apply)
A. Separate the patient from the caregiver to complete part of the assessment
B. Ask the caregiver to remain in the room for all assessments to reduce anxiety
C. Assess for signs of neglect such as poor hygiene, dehydration, and malnutrition
D. Document objective findings using exact descriptions
E. Conclude that abuse is occurring and confront the caregiver
F. Report suspected abuse according to facility and legal policy
Correct Answers: A, C, D, F
✔ A. Separate the patient from the caregiver to complete part of the assessment
Rationale (Correct):
❌ B. Ask the caregiver to remain in the room for all assessments to reduce anxiety
Rationale (Incorrect):
✔ C. Assess for signs of neglect such as poor hygiene, dehydration, and malnutrition
Rationale (Correct):
✔ D. Document objective findings using exact descriptions
Rationale (Correct):
❌ E. Conclude that abuse is occurring and confront the caregiver
Rationale (Incorrect):
✔ F. Report suspected abuse according to facility and legal policy
Rationale (Correct):
Which interventions should the nurse include in the care plan to prevent falls? (Select all that apply)
A. Place bed in high position for transfers
B. Keep call light within reach
C. Use bed alarm if needed
D. Provide frequent reorientation
E. Encourage independent ambulation without assistance
F. Keep environment clutter-free
Correct Answers: B, C, D, F
The nurse is reviewing a patient’s laboratory results. Which findings are abnormal and require further assessment? Select all that apply.
A. Albumin 2.8 g/dL
B. BUN 12 mg/dL
C. Potassium 5.8 mEq/L
D. Sodium 140 mEq/L
E. Specific gravity 1.035
F. Creatinine 0.9 mg/dL
Correct Answers: A, C, E
Rationales
A client with breakthrough cancer pain is already receiving around-the-clock analgesia. Which order would the nurse expect?
Multiple-Choice:
(A) An immediate-release opioid for episodic pain
(B) A longer-acting opioid only
(C) A diuretic to reduce inflammation
(D) A PRN antacid after each meal
Correct Answer: (A) An immediate-release opioid for episodic pain
Rationale: Breakthrough pain is typically treated with an immediate-release opioid in addition to the baseline around-the-clock regimen. A longer-acting opioid alone is not appropriate for rapid relief of transient pain. Diuretics and antacids do not treat breakthrough cancer pain.
nurse is providing discharge teaching to a patient newly prescribed Vasotec (enalapril) for hypertension.
Which statements by the patient indicate correct understanding? (Select all that apply)
A. “I should change positions slowly to prevent dizziness.”
B. “I can stop taking this medication once my blood pressure is normal.”
C. “I should monitor for a persistent dry cough.”
D. “I may need periodic blood tests to check kidney function and potassium.”
E. “I should increase potassium-rich foods like bananas without restrictions.”
F. “I will check my blood pressure regularly while taking this medication.”
Correct Answers: A, C, D, F
✔ A. “I should change positions slowly to prevent dizziness.”
Rationale (Correct):
❌ B. “I can stop taking this medication once my blood pressure is normal.”
Rationale (Incorrect):
✔ C. “I should monitor for a persistent dry cough.”
Rationale (Correct):
✔ D. “I may need periodic blood tests to check kidney function and potassium.”
Rationale (Correct):
❌ E. “I should increase potassium-rich foods like bananas without restrictions.”
Rationale (Incorrect):
✔ F. “I will check my blood pressure regularly while taking this medication.”
Rationale (Correct):
A nurse is caring for a patient diagnosed with Clostridioides difficile (C. diff) infection. The nurse is preparing to perform hand hygiene and provide patient care.
Which actions are appropriate? (Select all that apply)
A. Perform hand hygiene using soap and water after patient care
B. Use alcohol-based hand sanitizer after exiting the room
C. Wear gloves when providing direct patient care
D. Use contact precautions for the patient
E. Disinfect room surfaces with standard cleaning only (no bleach needed)
F. Teach staff that C. diff spores are resistant to alcohol-based sanitizers
Correct Answers: A, C, D, F
✔ A. Perform hand hygiene using soap and water after patient care
Rationale (Correct):
❌ B. Use alcohol-based hand sanitizer after exiting the room
Rationale (Incorrect):
✔ C. Wear gloves when providing direct patient care
Rationale (Correct):
✔ D. Use contact precautions for the patient
Rationale (Correct):
❌ E. Disinfect room surfaces with standard cleaning only (no bleach needed)
Rationale (Incorrect):
✔ F. Teach staff that C. diff spores are resistant to alcohol-based sanitizers
Rationale (Correct):
A nurse is assessing an 82-year-old patient who was admitted with new-onset confusion. The provider orders a Mini-Mental State Examination (MMSE).
Which findings are included in the MMSE? (Select all that apply)
A. Asking the patient to repeat three unrelated words immediately and after a delay
B. Checking pupil response to light
C. Having the patient identify the current date and location
D. Asking the patient to spell a word backward
E. Testing muscle strength in upper and lower extremities
F. Asking the patient to name common objects (e.g., pen, watch)
Correct Answers: A, C, D, F
✔ A. Asking the patient to repeat three unrelated words immediately and after a delay
Rationale (Correct):
❌ B. Checking pupil response to light
Rationale (Incorrect):
✔ C. Having the patient identify the current date and location
Rationale (Correct):
✔ D. Asking the patient to spell a word backward
Rationale (Correct):
❌ E. Testing muscle strength in upper and lower extremities
Rationale (Incorrect):
✔ F. Asking the patient to name common objects (e.g., pen, watch)
Rationale (Correct):
he nurse is caring for a hospitalized patient with a potassium level of 2.9 mEq/L. The patient is receiving furosemide for heart failure.
Which assessment finding should the nurse identify as the priority concern?
A. Blood pressure 148/86 mmHg
B. Muscle weakness and leg cramps
C. Apical heart rate irregular at 48 bpm
D. Urine output 45 mL/hr
Correct Answer: C — Apical heart rate irregular at 48 bpm
Rationales
NGN Clinical Judgment Breakdown
Recognize Cues
Analyze Cues
Hypokalemia increases risk for life-threatening dysrhythmias due to altered cardiac conduction.
Prioritize Hypothesis
Cardiac instability related to low potassium.
Take Action
Monitor ECG, anticipate potassium replacement, notify provider for abnormal rhythm.
Evaluate Outcomes
Stable heart rhythm, potassium returns to normal range, improved neuromuscular function.
The nurse is caring for a postoperative patient receiving IV morphine for pain management. Thirty minutes after administration, the nurse notes the following assessment findings:
Which action should the nurse take first?
A. Administer the prescribed PRN pain medication
B. Place the patient in high-Fowler’s position only
C. Administer naloxone as prescribed
D. Encourage the patient to cough and deep breathe
Correct Answer: C — Administer naloxone as prescribed
Rationales
A nurse is teaching a patient who is receiving IV vancomycin for a severe infection. The provider has ordered a vancomycin trough level.
Which statements by the patient indicate correct understanding? (Select all that apply)
A. “The blood sample will be drawn right before my next dose.”
B. “This test checks if the medication level is too high and could be toxic.”
C. “I should take my vancomycin dose before the blood test is drawn.”
D. “The goal is to make sure the drug is still at an effective level in my body.”
E. “This test is used to check my blood sugar levels.”
F. “If the level is too high, I may be at risk for kidney damage.”
Correct Answers: A, B, D, F
✔ A. “The blood sample will be drawn right before my next dose.”
Rationale (Correct):
✔ B. “This test checks if the medication level is too high and could be toxic.”
Rationale (Correct):
❌ C. “I should take my vancomycin dose before the blood test is drawn.”
Rationale (Incorrect):
✔ D. “The goal is to make sure the drug is still at an effective level in my body.”
Rationale (Correct):
❌ E. “This test is used to check my blood sugar levels.”
Rationale (Incorrect):
✔ F. “If the level is too high, I may be at risk for kidney damage.”
Rationale (Correct):
A nurse is providing preventive care for a 78-year-old patient during a routine visit.
Which interventions should the nurse include? (Select all that apply)
A. Recommend bone density screening
B. Encourage annual influenza vaccination
C. Advise limiting all physical activity to prevent injury
D. Assess fall risk and home safety hazards
E. Encourage increased calcium and vitamin D intake
F. Discourage vision and hearing evaluations unless symptoms occur
Correct Answers: A, B, D, E
✔ A. Recommend bone density screening
Rationale (Correct):
✔ B. Encourage annual influenza vaccination
Rationale (Correct):
❌ C. Advise limiting all physical activity to prevent injury
Rationale (Incorrect):
✔ D. Assess fall risk and home safety hazards
Rationale (Correct):
✔ E. Encourage increased calcium and vitamin D intake
Rationale (Correct):
❌ F. Discourage vision and hearing evaluations unless symptoms occur
Rationale (Incorrect):