Patient Safety
Q. A nurse is caring for a patient receiving oxygen at 2 L/min via nasal cannula. Which action is most important to promote patient safety?
Correct Response:
B. Keep oxygen away from open flames and smoking materials.
Rationale: Oxygen supports combustion. Keep oxygen away from flames, sparks, and smoking materials.
Q.A patient with type 1 diabetes is prescribed insulin lispro. When should the nurse administer this medication?
Answer:
Immediately before or shortly after starting a meal
Rationale: Insulin lispro is a rapid-acting insulin. It begins working quickly, so it should be administered close to mealtime to reduce the risk of hypoglycemia
Q: A patient with hypothyroidism reports fatigue, constipation, and cold intolerance. Which finding supports the diagnosis?
Answer: Elevated TSH, decreased T3/ T4
Q. Which mineral is essential for hemoglobin production and oxygen transport in the blood?
Answer:
Iron
Rationale
Q. A patient with diabetes has difficulty following the prescribed diet because the recommended foods are culturally unfamiliar and expensive. What is the nurse's best action
Answer: Collaborate with the patient and dietitian to develop an affordable meal plan that respects the patient's cultural food preferences.
Q. A patient with diabetes who is alert and able to swallow has a blood glucose level of 58 mg/dL. minutes.
1.How much glucose should nurse administer
2. How soon BS need to be retested?
Answer:The nurse should administer 15 grams of fast-acting carbohydrates and recheck the blood glucose in 15
Rationale: This follows the 15-15 rule for treating hypoglycemia. If the glucose remains below 70 mg/dL, repeat treatment. Once corrected, provide a snack or meal if needed
Q. A patient taking furosemide (Lasix) for fluid overload should be monitored for which electrolyte imbalance?
Answer: Hypokalemia
Rationale: Furosemide is a loop diuretic that increases potassium excretion in the urine. Low potassium can increase the risk of muscle weakness and cardiac dysrhythmias.
Q: The nurse is receiving reports on four patients. Which patient should the nurse assess first?
A. A patient with hypothyroidism reporting constipation and fatigue.
B. A patient with diabetes who is shaky, sweaty, and has a blood glucose of 52 mg/dL.
C. A patient with iron-deficiency anemia reporting weakness.
D. A patient with COPD whose oxygen saturation is 90%
Answer B:
Rationale: The patient has symptomatic hypoglycemia, which can rapidly progress to seizures, loss of consciousness, and brain injury. Immediate intervention is necessary.
Q. Which hormone increases blood glucose levels by stimulating the liver to break down stored glycogen?
Answer:
Glucagon
Rationale: Glucagon is produced by the alpha cells of the pancreas. It increases blood glucose by stimulating the liver to break down stored glycogen into glucose and release it into the bloodstream.
Q. A nurse is caring for a patient who speaks limited English. The patient needs education about a newly prescribed diabetes medication. What is the most appropriate nursing action?
Answer: Arrange for a qualified medical interpreter.
Rationale: A qualified medical interpreter helps ensure accurate communication, patient understanding, and safe medication administration. Family members should not routinely be used as interpreters.
Q. A patient receiving a blood transfusion suddenly develops chills, fever, and lower back pain. Which actions should the nurse take?
At least 3 responses
Correct responses
A. Stop the blood transfusion immediately.
B. Keep the IV line open with normal saline using new tubing.
D. Notify the healthcare provider and blood bank.
Rationale: These may be signs of an acute transfusion reaction. Stop the transfusion, maintain IV access with normal saline using new tubing, and notify the appropriate personnel
Q. Which instructions should the nurse provide to a patient taking oral ferrous sulfate?
At least 3 responses
A. Take with vitamin C if tolerated
B. Expect possible dark stools.
D. Increase dietary fiber if constipation occurs.
Rationale: Vitamin C improves iron absorption. Iron can cause dark stools and constipation.
Q: A patient with Graves' disease presents with heart rate 138 bpm, temperature 40°C (104°F), agitation, and vomiting. What complication should the nurse suspect?
Answer: Thyroid storm
Rationale: Severe hyperthyroidism can progress to thyroid storm, a life-threatening emergency involving hyperthermia, tachycardia, and altered mental status
Q. Which gland produce cortisol, a hormone that helps the body respond to stress and can increase blood glucose.
Answer:
Adrenal gland
Q. A nurse assumes that an older adult patient cannot understand discharge instructions because of the patient's age and directs all teaching to the patient's adult child.
State True or False
What are 2 appropriate actions?
Answer: False (This is age-based stereotyping)
Rationale:
Nurses should communicate directly with the patient,
Assess their ability and preferences
Include family members only with the patient's permission
Q. A patient with diabetes is found sweating, trembling, and confused. The blood glucose level is 48 mg/dL. The patient is awake and able to swallow safely. Place the nursing actions in the correct order.
A. Recheck blood glucose after 15 minutes.
B. Administer 15 g of fast-acting carbohydrates.
C. Assess the patient's level of consciousness and ability to swallow.
D. Repeat treatment if blood glucose remains below 70 mg/dL.
Answers:
C Assess pt's LOC and swallow ability
B Give 15 gm of fast acting glucose
A Recheck the blood glucose in 15 min
D Repeat treatment if BS <70 mg/DL
Q. The nurse is teaching a patient who is prescribed levothyroxine for hypothyroidism. Which instructions should the nurse include?
Correct responses;
A. Take the medication on an empty stomach (for better absorption)
B. Take the medication at the same time every day (for stable level)
D. Separate calcium and iron supplements from levothyroxine by about 4 hours (to avoid interference)
Q. A patient with asthma reports increasing shortness of breath and chest tightness. The nurse measures the patient's peak expiratory flow reading of 150 L/Min. Personal best: 400 L/min
Which asthma action zone does this reading indicate?
What should the nurse do next?
Correct Responses:
Red zone – Emergency zone. Less than 50% of personal best.
Initiate the patient's prescribed emergency asthma action plan, administer prescribed rapid-acting bronchodilator, assess airway and breathing
Rationale:
Green zone: 80–100% of personal best (doing well).
Yellow zone: 50–79% (caution; asthma may be worsening).
Red zone: Below 50% (medical alert; immediate action required).
Q. Which laboratory finding is most commonly associated with pernicious anemia?
Why?
2 responses
Answer:
Vitamin B12 deficiency
Body is not producing enough intrinsic factor
Rationale: Pernicious anemia occurs when the body cannot properly absorb vitamin B12, usually because the stomach does not produce enough intrinsic factor.
Q. A nurse is caring for a patient who has a visual impairment and is newly diagnosed with diabetes. The patient needs education on how to administer insulin independently. What is the BEST nursing intervention?
2 resposnes
Answer: Provide teaching materials with large print or audio instructions
Demonstrate insulin administration using hands on guidance
Q. A nurse is caring for a patient with COPD who is receiving oxygen at 2 L/min via nasal cannula. The patient suddenly becomes drowsy and confused. ABG results show:
pH: 7.25
PaCO₂: 70 mmHg
HCO₃: 29 mEq/L
PaO₂: 55 mmHg
What is the nurse's PRIORITY actions?
Answer:
Assess airway and breathing
urgently notify the healthcare team
prepare for possible ventilatory support while titrating oxygen to the prescribed target.
Q: A nurse is preparing to administer NPH insulin and regular insulin to a patient with diabetes. Which actions are appropriate?
Answers:
Answers:
A. Draw up regular insulin before NPH insulin (regular insulin is clear and NPH is cloudy)
B. Roll the NPH insulin vial gently between the palms to mix it.
C) Inject air into the NPH vial first, then into the regular insulin vial; withdraw regular insulin first.
Q. Signs and symptoms of hypothyroidism
At least 5-6 responses
Answer: Fatigue, weakness
weight gain
Cold intolerance
Dry rough skin
bradycardia
constipation
Q. Which findings are commonly associated with iron-deficiency anemia?
Correct Response:
Fatigue and weakness
shortness of breath with activity
Pallor of the skin and mucous membrane due to reduced Hg
Q.A transgender patient is admitted to the hospital. A staff member repeatedly uses the patient's previous name and incorrect pronouns despite being corrected. What should the nurse do?
3 responses
Answers:
Use the patient's correct name and pronouns
Respectfully address the staff member's behavior
Advocate for the patient's dignity.