Airway/Breathing
A nurse is receiving shift report on four clients. Which client should the nurse assess first?
A. A client with chronic obstructive pulmonary disease (COPD) who has a pulse oximetry reading of 89% on room air.
B. A client with a history of asthma who is coughing up thick, white sputum.
C. A client who underwent a thyroidectomy 6 hours ago and has developed a hoarse voice and audible stridor.
D. A client with pneumonia who has an oral temperature of 101.2°F (38.4°C).
Correct Answer: C. Audible stridor indicates a compromised airway and acute respiratory distress, requiring immediate intervention.
Which client should the nurse evaluate first during morning rounds?
A. A client with hypertension whose blood pressure is 142/88 mm Hg.
B. A client with a history of angina who reports chest pain radiating to the jaw.
C. A client with atrial fibrillation whose heart rate is 88 beats per minute.
D. A client recovering from an appendectomy who has a heart rate of 96 beats per minute.
Correct Answer: B. Active chest pain radiating to the jaw indicates acute myocardial ischemia (potential heart attack) and is the highest circulatory priority.
A client with a head injury has a Glasgow Coma Scale (GCS) score that changed from 13 to 10 over the last hour. What is the nurse's priority action?
A. Document the score and reassess in one hour.
B. Ask the client to repeat their name and date of birth.
C. Notify the charge nurse and the healthcare provider immediately.
D. Check the client's pupillary response to light.
Correct Answer: C. A decrease in the GCS score indicates a significant neurological decline and potential increased intracranial pressure, requiring immediate emergency intervention.
The nurse is preparing to administer digoxin to a client with heart failure. The client’s apical pulse is 54 beats per minute. What is the nurse's priority action?
A. Administer the medication and document the heart rate.
B. Administer half of the prescribed dose.
C. Hold the medication and notify the healthcare provider.
D. Wait 30 minutes and recheck the radial pulse
Correct Answer: C. Digoxin should be held if the apical pulse is less than 60 beats per minute in an adult, followed by notifying the provider.
The nurse is caring for a client who is scheduled for an elective surgery in 2 hours. The client states, "I signed the consent form, but I still don’t really understand what the surgeon is going to cut." What is the nurse's priority action?
A. Reassure the client that the surgeon is highly skilled.
B. Explain the surgical steps in simple terms to the client.
C. Contact the surgeon to return and explain the procedure to the client.
D. Document that the client has anxiety regarding the surgery.
Correct Answer: C. While the nurse can witness a signature, it is the surgeon's legal responsibility to provide informed consent and explain the procedure. If the client lacks understanding, the surgeon must be notified to clarify.
An LPN is caring for a client who is choking but remains conscious. After determining the client cannot speak, what is the immediate action the nurse should take?
A. Administer 5 back blows.
B. Perform abdominal thrusts (Heimlich maneuver).
C. Begin cardiopulmonary resuscitation (CPR).
D. Open the airway using the jaw-thrust maneuver.
Correct Answer: B. Abdominal thrusts are the standard immediate intervention for a conscious adult with a severe airway obstruction.
An LPN is monitoring a client receiving a blood transfusion. Within 15 minutes, the client complains of chills, lower back pain, and nausea. Which action should the nurse take first?
A. Slow the transfusion rate and check vital signs.
B. Stop the transfusion immediately.
C. Administer the prescribed PRN diphenhydramine.
D. Recheck the client’s identification band against the blood bag.
Correct Answer: B. These symptoms indicate an acute hemolytic transfusion reaction. The transfusion must be stopped immediately to prevent further harm.
The nurse is caring for a client with a history of tonic-clonic seizures. The client suddenly cries out and begins having a seizure. Which action should the nurse take first?
A. Insert a padded tongue blade into the client’s mouth.
B. Restrain the client's arms and legs to prevent injury.
C. Turn the client onto their side and clear the surrounding area.
D. Leave the room to get the emergency seizure medication.
Correct Answer: C. Turning the client onto their side protects the airway from aspiration and clearing the area prevents musculoskeletal injury.
A client is scheduled to receive a dose of regular insulin at 0730. The nurse checks the fingerstick blood glucose at 0700 and notes it is 52 mg/dL. Which action should the nurse take first?
A. Administer the regular insulin as scheduled.
B. Hold the insulin and give the client 4 ounces of orange juice.
C. Call the healthcare provider to report the blood glucose level.
D. Recheck the blood glucose level in one hour.
Correct Answer: B. The client is hypoglycemic. According to the "rule of 15," the immediate action is to administer 15 grams of fast-acting carbohydrates (like orange juice) and hold the insulin
The nurse is caring for an older adult client who is being treated for a urinary tract infection (UTI). Which change in status is the most critical early indicator that the client may be developing urosepsis?
A. The client's urine remains cloudy and foul-smelling.
B. The client becomes acutely confused and disoriented to time and place.
C. The client reports mild burning during urination.
D. The client's white blood cell count is slightly elevated.
Correct Answer: B. In older adults, acute mental status changes (delirium) are often the earliest signs of systemic infection or sepsis
The nurse notes that a client with a chest tube has continuous bubbling in the water seal chamber. Which action should the nurse take first?
A. Increase the wall suction pressure.
B. Check the system for air leaks starting at the insertion site.
C. Clamp the chest tube close to the client's chest.
D. Document the finding as a normal expected outcome.
Correct Answer: B. Continuous bubbling in the water seal chamber indicates an air leak. The nurse must systematically locate the leak.
A client with heart failure reports a sudden weight gain of 4 pounds over the last 2 days and increased shortness of breath while resting. What is the nurse’s priority action?
A. Auscultate the client's lung sounds.
B. Teach the client about restricting fluid intake.
C. Administer a PRN dose of acetaminophen for discomfort.
D. Re-weigh the client using a different scale.
Correct Answer: A. Rapid weight gain and dyspnea indicate acute fluid volume overload and potential pulmonary edema. The nurse must assess lung sounds immediately to determine severity.
A nurse enters a client's room and finds the client confused, agitated, and pulling at their intravenous (IV) line. What is the nurse's priority safety intervention?
A. Apply bilateral wrist restraints to protect the line.
B. Request a prescription for a sedative medication.
C. Stay with the client and attempt to reorient or distract them.
D. Move the client closer to the nurse's station immediately.
Correct Answer: C. The least restrictive safety measure should always be attempted first. Staying with and reorienting the client is the safest initial action.
A nurse is reviewing a client’s laboratory results and notes a potassium level of 6.2 mEq/L. Which assessment should the nurse perform immediately?
A. Assess the client’s deep tendon reflexes.
B. Check the client’s heart rate and cardiac rhythm.
C. Monitor the client’s hourly urine output.
D. Evaluate the client for muscle cramping in the legs.
Correct Answer: B. Hyperkalemia (potassium > 5.0 mEq/L) poses a severe risk for life-threatening cardiac arrhythmias and cardiac arrest.
An LPN is working with an experienced unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP?
A. Feeding a client with dysphagia who has a history of aspiration.
B. Re-positioning a stable client who is 3 days postoperative from a spinal fusion.
C. Teaching a client how to use an incentive spirometer.
D. Assessing a client's surgical wound for signs of infection.
Correct Answer: B. Re-positioning a stable postoperative client is a routine care task within the scope of a trained UAP. Feeding an aspiration risk, teaching, and assessment all require nursing judgment.
A client with deep vein thrombosis (DVT) suddenly develops sharp chest pain and severe dyspnea. Which intervention should the nurse perform first?
A. Obtain a 12-lead electrocardiogram (ECG).
B. Administer the prescribed PRN pain medication.
C. Raise the head of the bed and administer oxygen.
D. Call the health care provider immediately.
Correct Answer: C. The client's symptoms suggest a pulmonary embolism. Elevating the head of the bed and supplying oxygen optimizes gas exchange immediately before calling the provider.
The nurse is caring for a client who returned from a cardiac catheterization 2 hours ago. Which finding requires immediate follow-up?
A. The client reports mild discomfort at the insertion site.
B. The insertion site dressing is dry and intact.
C. The pedal pulse on the affected extremity is faint compared to baseline.
D. The client’s blood pressure has decreased from 130/80 to 122/76 mm Hg.
Correct Answer: C. A diminished or faint pedal pulse indicates potential arterial occlusion or hematoma formation, compromising peripheral perfusion.
The nurse is caring for an older adult client who is confused and at high risk for falls. Which intervention is the most effective priority safety measure?
A. Keep all four side rails raised at all times.
B. Place a bed alarm on the client's bed and keep the bed in the lowest position.
C. Administer a mild sedative at bedtime to prevent wandering.
D. Request that a family member stay with the client 24 hours a day.
Correct Answer: B. Bed alarms and low bed heights provide safety without violating restraint guidelines (four side rails can be considered a restraint).
The nurse is preparing to administer morning medications to a group of clients. Which medication should be administered first?
A. A daily multivitamin scheduled for 0900.
B. A calcium carbonate supplement scheduled for 0900.
C. A prescribed rapid-acting insulin for a client whose breakfast tray just arrived.
D. A scheduled stool softener for a client who hasn't had a bowel movement in 2 days.
Correct Answer: C. Rapid-acting insulin must be synchronized with food intake to prevent severe hypoglycemia
A client who is terminally ill with cancer is crying and says, "I don't think I can handle this pain anymore." What is the nurse's priority psychosocial response?
A. "Don't worry, your doctor is very good at managing cancer pain."
B. "Would you like me to call the hospital chaplain to speak with you?"
C. "Tell me more about what you are feeling right now."
D. "I will go get you your scheduled pain medication immediately."
Correct Answer: C. Using an open-ended communication technique allows the client to express their feelings and helps the nurse assess both the physical and emotional components of their pain.
The nurse administers an intramuscular penicillin injection to a client. Ten minutes later, the client reports feeling dizzy and itchy, with a tight feeling in the throat. What is the nurse's priority action?
A. Apply a cold compress to the injection site.
B. Take the client's blood pressure and pulse.
C. Prepare to administer prescribed epinephrine.
D. Instruct the client to take deep, slow breaths.
Correct Answer: C. The client is exhibiting signs of anaphylaxis, a life-threatening emergency. Epinephrine is the priority first-line treatment.
While reviewing laboratory results for four clients, which result requires the nurse to notify the healthcare provider immediately?
A. A client on warfarin with an INR of 2.5.
B. A client taking digoxin with a serum potassium level of 2.8 mEq/L.
C. A client with diabetes mellitus and a fasting blood glucose of 140 mg/dL.
D. A client with chronic kidney disease and a serum creatinine of 1.6 mg/dL.
Correct Answer: B. Hypokalemia (potassium < 3.5 mEq/L) significantly increases the risk of life-threatening digoxin toxicity and cardiac arrhythmias.
A client who is 2 days postoperative from a hip replacement becomes acutely confused, hallucinates, and tries to climb out of bed. After ensuring client safety, which action should the nurse prioritize next?
A. Check the client’s oxygen saturation and vital signs.
B. Request a psychiatric consultation.
C. Administer a prescribed dose of haloperidol.
D. Ask the family if the client has a history of dementia.
Correct Answer: A. Acute confusion (delirium) in a postoperative patient can be caused by physical factors like hypoxia, infection (UTI), or electrolyte imbalances. Vital signs and O2 sat must be checked first to rule out life-threatening physiological causes.
A client is receiving an intravenous infusion of heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 110 seconds (therapeutic range is 45 to 70 seconds). Which action should the nurse take first?
A. Stop the heparin infusion immediately.
B. Decrease the infusion rate by half.
C. Administer Vitamin K intramuscularly.
D. Notify the RN assigned to the patient .
Correct Answer: D. An aPTT of 110 seconds is dangerously high, putting the patient at critical risk for hemorrhage. The priority is to immediately contact the RN to stop the infusion to prevent bleeding.
A nurse is assigned to care for four clients on a medical-surgical unit. Which client should be assessed first after change-of-shift report?
A. A client who had a total knee replacement yesterday and reports pain as 6 out of 10.
B. A client admitted with gastroenteritis who has had 2 loose stools during the night.
C. A client with type 1 diabetes who is trembling, diaphoretic, and slurring their words.
D. A client with a permanent pacemaker who is scheduled for discharge this morning.
Correct Answer: C. Trembling, diaphoresis, and slurred speech indicate severe hypoglycemia, an unstable physiological crisis requiring immediate assessment and glucose administration.