WHO DIES FIRST?
The nurse receives report on four clients. Which client should be assessed FIRST?
A. A client admitted with CHF who gained 5 pounds in 2 days and has bilateral crackles
B. A client with a GI bleed whose hemoglobin dropped from 12 to 8 over 24 hours and now reports dizziness when standing
C. A client with COPD whose oxygen saturation is 88% on 2L NC (baseline 88-90%)
D. A client receiving IV vancomycin who reports itching and has flushing of the face
B. A client with a GI bleed whose hemoglobin dropped from 12 to 8 over 24 hours and now reports dizziness when standing
Rationale: active blood loss with symptomatic hypovolemia and potential shock
Which order should the nurse question?
A. Give potassium chloride PO for K⁺ 3.2
B. Give furosemide for crackles and edema
C. Give potassium chloride IV push for K⁺ 2.8
D. Place client with chest pain on cardiac monitor
C. Give potassium chloride IV push for K⁺ 2.8
Rationale: Potassium is never given IV push. It can cause fatal dysrhythmias.
Which lab requires immediate follow-up?
A. Sodium 132
B. Potassium 6.7
C. WBC 12,000
D. Hemoglobin 10.2
B. Potassium 6.7
Rationale: Severe hyperkalemia can cause fatal cardiac dysrhythmias.
A laboring client has sudden fetal bradycardia after rupture of membranes. What should the nurse suspect?
A. Placenta previa
B. Cord prolapse
C. Gestational diabetes
D. Hyperemesis
B. Cord prolapse
Rationale: Rupture of membranes plus fetal bradycardia = possible cord prolapse.
A nurse reviews the following assessment findings on a client admitted with pneumonia:
Which finding most strongly suggests the client's condition is deteriorating?
A. Elevated WBC
B. Fever
C. Tachycardia
D. New confusion
D. New confusion
Rationale: acute change in mental status is often an early sign of poor cerebral perfusion and sepsis progression.
The nurse receives report on four clients. Which client should be assessed FIRST?
A. A client 8 hours post-op with a urine output of 25 mL/hr for the last 2 hours
B. A client with sepsis whose lactate increased from 2.1 to 4.8 despite IV fluids
C. A client with chest pain relieved by nitroglycerin
D. A client with atrial fibrillation whose heart rate is 118
B. A client with sepsis whose lactate increased from 2.1 to 4.8 despite IV fluids
Rationale: Sepsis + rising lactate despite treatment = worsening tissue hypoperfusion. This patient is actively progressing toward septic shock.
A client has a platelet count of 38,000. Which order should the nurse question?
A. Apply bleeding precautions
B. Avoid IM injections
C. Administer aspirin for headache
D. Use soft toothbrush
C. Administer aspirin for headache
Rationale: Aspirin increases bleeding risk.
A client taking lithium reports vomiting, diarrhea, tremors, and confusion. What is the priority action?
A. Give the next dose with food
B. Hold lithium and notify provider
C. Encourage ambulation
D. Document expected side effects
B. Hold lithium and notify provider
Rationale: These are signs of lithium toxicity.
A postpartum client has a boggy uterus and heavy bleeding. What should the nurse do first?
A. Call provider
B. Massage the fundus
C. Administer oxygen
D. Check hemoglobin
B. Massage the fundus
Rationale: Boggy uterus = uterine atony. Fundal massage first.
A nurse is caring for a client admitted with stroke-like symptoms.
Assessment findings:
Which action should the nurse take FIRST?
D. Treat the blood glucose
Rationale: Hypoglycemia can completely mimic stroke. Correcting the glucose comes before everything else.
Four clients arrive at the same time. Who is highest priority?
A. Stroke symptoms that began 20 minutes ago
B. Blood pressure 84/48 after vomiting blood
C. New onset chest pain with nausea
D. Stridor after receiving IV antibiotic
D. Stridor after receiving IV antibiotic
Rationale: Stridor = airway swelling. Airway beats circulation.
A client with myasthenia gravis is prescribed which medication that the nurse should question?
A. Pyridostigmine
B. Prednisone
C. Ciprofloxacin
D. Acetaminophen
C. Ciprofloxacin
Rationale: Fluoroquinolones can worsen myasthenia gravis.
A client receiving heparin has platelets drop from 240,000 to 88,000. What should the nurse suspect?
A. Expected response
B. Heparin-induced thrombocytopenia
C. Iron deficiency anemia
D. Dehydration
B. Heparin-induced thrombocytopenia
Rationale: HIT causes thrombocytopenia and dangerous clotting risk.
A child with epiglottitis is drooling, sitting forward, and appears anxious. What should the nurse do?
A. Inspect the throat with tongue blade
B. Place child supine
C. Prepare for emergency airway support
D. Offer oral fluids
C. Prepare for emergency airway support
Rationale: Epiglottitis can cause sudden airway obstruction.
A client with chest pain receives nitroglycerin. Five minutes later BP is 82/48. What should the nurse do?
A. Give another nitroglycerin
B. Place client supine and notify provider
C. Encourage deep breathing
D. Document expected effect
B. Place client supine and notify provider
Rationale: Nitroglycerin can cause severe hypotension.
Which post-op client requires immediate assessment?
A. 12 hours post-op with absent bowel sounds
B. 4 hours post-op with urine output 20 mL/hr
C. 2 hours post-op with restlessness and HR 128
D. 24 hours post-op with temperature 100.4°F
C. 2 hours post-op with restlessness and HR 128
Rationale: Restlessness and tachycardia may indicate bleeding, shock, hypoxia, or PE.
A client with heart failure has potassium 2.9 and is prescribed digoxin. What should the nurse do?
A. Give digoxin as ordered
B. Hold digoxin and notify provider
C. Give digoxin with food
D. Recheck pulse in 30 minutes
B. Hold digoxin and notify provider
Rationale: Low potassium increases risk for digoxin toxicity.
A client with renal failure is prescribed magnesium hydroxide for constipation. What should the nurse do?
A. Administer as ordered
B. Hold and question the order
C. Give with extra fluids
D. Give after dialysis only
B. Hold and question the order
Rationale: Renal failure increases risk for magnesium toxicity.
A newborn is jittery, cyanotic, and has a weak cry. What should the nurse assess first?
A. Temperature
B. Blood glucose
C. Weight
D. Bowel sounds
B. Blood glucose
Rationale: Neonatal hypoglycemia can present with jitteriness, cyanosis, and poor feeding/cry.
A client with pneumonia becomes confused, RR 32, BP 86/50, and urine output 15 mL/hr. What is the priority concern?
A. Anxiety
B. Worsening sepsis
C. Medication side effect
D. Dehydration only
B. Worsening sepsis
Rationale: Confusion, hypotension, tachypnea, and low urine output suggest septic shock.
The nurse receives report on four clients. Who should be assessed first?
A. DKA client with potassium 3.0
B. Sepsis client with lactate 5.4
C. Stroke symptoms with blood glucose 39
D. Post-op client with RR 8 after IV morphine
D. Post-op client with RR 8 after IV morphine
Rationale: Respiratory depression is an immediate airway/breathing emergency.
A client with suspected increased intracranial pressure has which order that should be questioned?
A. Keep head of bed at 30 degrees
B. Neurological checks every hour
C. Suction every 2 hours routinely
D. Maintain quiet environment
C. Suction every 2 hours routinely
Rationale: Routine suctioning can increase ICP. Suction only when necessary.
A client with DKA has glucose 580 and potassium 3.1. Which order is priority before insulin?
A. Administer regular insulin IV
B. Administer potassium replacement
C. Restrict fluids
D. Give sodium bicarbonate
B. Administer potassium replacement
Rationale: Insulin lowers potassium further. Hypokalemia must be corrected first.
A pregnant client has severe abdominal pain, rigid abdomen, vaginal bleeding, and late decelerations. What is most likely?
A. Placenta previa
B. Placental abruption
C. Normal labor
D. Preeclampsia only
B. Placental abruption
Rationale: Painful bleeding with rigid abdomen and fetal distress suggests abruption.
A client on oxygen becomes increasingly drowsy. ABGs: pH 7.28, PaCO₂ 68, HCO₃ 29. What is happening?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
C. Respiratory acidosis
Rationale: Low pH and high CO₂ = respiratory acidosis, likely CO₂ retention.