Sorting Hat Decisions
The nurse is caring for four patients. Who should be assessed FIRST?
A. COPD patient with O₂ sat 90% on 2 L NC and stable respirations
B. Post-op patient reporting 7/10 incisional pain
C. Stroke patient with right-sided weakness waiting for discharge teaching
D. Post-op hip replacement patient who is now confused and restless
Correct Answer: - D, post op hip replacement patient who is now confused and restless
Rationale: Acute mental status changes could indicate hypoxia or a post op complication. Assess this patient first - vitals, o2, LOC, mentation. Gather data and notify physician
While receiving a blood transfusion, the patient develops chills and complains of back pain. What is the first action the nurse should take?
A. Notify the provider
B. Administer acetaminophen
C. Stop the transfusion
D. Flush the line with NS
Correct answer: C - Stop the transfusion
Rationale: The patient is having an adverse reaction to blood products. The first step is to STOP what is causing the reaction. Do this before notifying the provider.
A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream?
A. Glucose
B. Ammonia
C. Potassium
D. Bicarbonate
Correct answer: B - ammonia
Rationale: Lactulose, a disaccharide, is a sugar that works as an osmotic diuretic. It prevents absorption of ammonia in the colon. Accumulation of ammonia in the bloodstream, which occurs in pathologic conditions of the liver, such as cirrhosis, may affect the central nervous system, causing hepatic encephalopathy or coma.
Nursing and clinical judgement is needed here to explain to the patient WHY he is getting this medication and it is not because of constipation.
You are caring for a a chronic trach patient who suddenly coughs and dislodges their tracheostomy. They are quickly becoming cyanotic. What is the first action?
A. Call rapid response
B. Use bag-valve mask over stoma
C. Insert new trach tube immediately
D. Apply O₂ via nasal cannula
Correct answer: B - use BVM over stoma to ventilate
Rationale: You need to take action quickly. This question tells you the patient has lost their airway and is already cyanotic. You can use a BVM over the stoma to attempt ventilation. Call for help and have someone call a rapid response. Calling a rapid first delays care. Applying a nasal cannula will not help the patient VENTILATE. Inserting a new trach tube is outside of your nursing scope.
A 72-year-old patient with pneumonia is admitted to the ICU. The nurse notes the following:
Temp: 103.2°F (39.6°C)
BP: 82/46
HR: 138, weak and thready
RR: 28, SpO₂ 88% on 6 L O₂ NC
Skin: mottled, cool extremities
Patient is restless and confused
Which action should the nurse take FIRST?
A. Increase oxygen delivery by non-rebreather mask
B. Obtain blood cultures before starting antibiotics
C. Begin a rapid IV infusion of 0.9% normal saline
D. Notify the provider of the patient’s condition
Correct answer: A - Increase oxygen delivery by non-rebreather mask
Rationale: Although fluids and antibiotics are critical for sepsis, ABCs rule first — this patient is in septic shock with hypoxia. Improving oxygenation is the immediate life-saving intervention.
Which patient would the nurse assess FIRST?
A. CHF patient with weight gain of 2 lbs in 24 hrs
B. Diabetic patient with blood glucose 58 mg/dL and diaphoresis
C. Pneumonia patient reporting cough with green sputum
D. Patient with ankle fracture requesting pain medication
Correct Answer - B, diabetic patient with blood glucose of 58 and diaphoresis
Rationale: This patient is having symptomatic hypoglycemia. Delaying treatment could be life threatening.
A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?
A. The client has hypotension and is confused
B. The client becomes bradycardic and has bradypnea
C. The client is hypertensive and anuric
D. The client has metabolic alkalosis and warm extremities
Correct Answer: A - the client has hypotension and is confused
Rationale: Clinical manifestations vary based on what type and what phase of shock the client is experiencing. Common manifestations include tachycardia, tachypnea, hypotension, abnormal mental status, mottled skin, cold and clammy extremities, oliguria, hyperlactatemia, and metabolic acidosis.
A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication?
A. Constipation
B. Black colored stools
C. Staining of the teeth
D. Red-tinged urine
Correct answer: D - Red-tinged urine
Rationale: Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.
Why is this considered clinical judgement? If you go in to assess your patient and notice they have red-tinged urine, connect the dots to the rifampin. Knowing that is likely the cause will save the patient a battery of unnecessary testing and worry. If the patient has other concerning symptoms, it may require further investigation, but it is always important to know which medications have side effects such as this.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
A. A room with air exhaust directly to the outdoor environment
B. A room with another non-surgical patient
C. A room in the ICU
D. A room that is within view of the nurse's station
Correct Answer: A - a room with air exhaust directly to the outdoor environment
Rationale: A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room (negative pressure room)
An active TB patient should have a private room as to not risk infecting another patient. This patient may not require an ICU as the question does not give you information that states they are critical. Typically TB in a patient with no other comorbidities does not require critical care. The room does not necessarily need to be in view of the nurse's station.
A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take?
A. Immobilize the affected limb with a splint and ask him not to move.
B. Make a thorough assessment of the circumstances surrounding the accident.
C. Put him in semi-Fowler’s position for comfort.
D. Check the pedal pulse and blanching sign in both legs.
Correct Answer: A- immobilize the affected limb
Rationale:
Airway, breathing, circulation are intact (he’s alert and conscious).
Severe pain + possible femur fracture = risk of bone displacement, hemorrhage, and fat embolism.
First priority is to prevent further injury and reduce risk of embolus/bleeding by immobilizing immediately.
Which patient requires immediate intervention?
A. 45-year-old with appendicitis reporting 6/10 pain
B. 72-year-old with pneumonia, RR 32, O₂ sat 86%
C. 24-year-old post-cholecystectomy requesting antiemetic
D. 60-year-old with chronic COPD and productive cough
Correct Answer: B - 72-year-old with pneumonia, RR 32, O₂ sat 86%
Rationale: ABCs - this answer choice involves airway and breathing compromise. See this patient first!
A patient receiving total parenteral nutrition (TPN) through a central line suddenly develops shortness of breath, chest pain, and is visibly anxious. Vitals: HR 132, BP 86/50, SpO₂ 82% on room air.
What is the nurse’s FIRST action?
A. Notify the healthcare provider immediately
B. Place the patient in Trendelenburg position on the left side
C. Administer oxygen by non-rebreather mask
D. Clamp the IV tubing and remove the central line
Correct answer: B - place the patient in Trendelenburg position on the left side
Rationale: This is a suspected air embolism via the central line. Placing the patient in left Trendelenburg can trap air in right atrium and prevent it from entering pulmonary circulation. Oxygen follows as second step.
The nurse is providing care for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is critically ill. Which of the following lab findings requires immediate intervention?
A. BUN of 24 mg/dl
B. Serum sodium of 125 mEq/L
C. Serum potassium of 5.0 mEq/L
D. Serum calcium of 8.0 mg/dl
Correct answer: B - sodium 125
Rationale: This lab finding is less than the expected reference range for sodium of 135 to 145 mEq/L. Hyponatremia is associated with significant morbidity and mortality for clients. The BUN is elevated, but not a critical lab for this patient. Potassium is within normal range. Calcium is decreased but this is not the critical lab.
An hour after admission to the nursery, the nurse observes a newborn baby having spontaneous jerky movements of the limbs. The infant’s mother had gestational diabetes mellitus (GDM) during pregnancy. Which of the following actions should the nurse take FIRST?
A. Give dextrose
B. Call the physician immediately
C. Determine the blood glucose level
D. Observe closely for other symptoms
Correct answer: C - determine the blood glucose level
Rationale: For this question, the nurse needs to gather more data. Connect the dots here - the question tells you the mother had GDM. We can assume the newborn is used to having a higher circulating glucose from the mother. Now, they do not have that. This means they are at risk for hypoglycemia. But - before we do anything, we need to check the glucose! Calling the doctor is important, but they are going to ask you "what is the glucose?" And what do you say if you haven't checked that yet?
A client is admitted with chest pain. Client is diaphoretic and short of breath. Client states, "Pain started when I began raking leaves in my yard." Pain "radiates to left arm and is a sharp pain." Cardiac enzymes indicate client is experiencing myocardial infarction. Provider notified and instructed nurse to prepare client for cardiac catheterization immediately. Which of the following actions should the nurse take? Select all that apply:
A. Mark the surgical site.
B. Witness the client’s signature on the informed consent form.
C. Obtain the client's vital signs.
D. Inform the client of the risks of the procedure.
E. Confirm the client's allergies.
Correct answer: B, C, and E
Rationales:
Witness the client’s signature on the informed consent form is correct. After the client's provider explains the procedure the nurse should witness the client's signature on the informed consent form.
Inform the client of the risks of the procedure is incorrect. The client's provider, rather than the nurse, is the responsible for explaining the procedure to the client. This involves informing the client of the potential risks of the procedure, as well as any alternative treatment options.
Obtain the client's vital signs is correct. The nurse should obtain the client's vital signs and notify the preoperative nurse of any values that are outside the expected reference range.
Confirm the client's allergies is correct. The nurse should confirm the client's allergies and verify an allergy band has been applied to the client’s wrist. The client's allergies should also be listed in their medical record.
Mark the surgical site is incorrect. The provider who will be performing the procedure, rather than the nurse, is responsible for marking the surgical site.
You are working in the emergency department and four patients arrive at the same time. Which patient should you see first?
A. A 58-year-old with chest pain 7/10 radiating to the left arm, diaphoretic, BP 110/60, HR 112
B. A 24-year-old with a history of asthma, audible wheezing, RR 28, SpO₂ 93% on room air, speaking in full sentences
C. A 70-year-old with a urinary tract infection, fever 101.8°F, reports burning with urination, vitals otherwise stable
D. A 40-year-old with a closed forearm fracture, obvious swelling and deformity, reports severe pain 9/10
Correct answer: A - A 58-year-old with chest pain 7/10 radiating to the left arm, diaphoretic, BP 110/60, HR 112
Rationale: Chest pain with hemodynamic instability (decreasing BP, tachycardia, diaphoresis). This patient could be having an MI and needs assessment and treatment immediately. Asthma patient is uncomfortable but stable (can speak in full sentences, oxygenation borderline but not crashing). UTI is uncomfortable but not life-threatening in this stable presentation. Fracture is painful but circulation and airway are intact.
A 40-year-old patient is 1 hour post-abdominal surgery. The nurse enters the room and notes:
Dressing saturated with bright red blood
HR 124, BP 88/56, skin cool and clammy
Patient is restless, saying, “I don’t feel right.”
Which action is the nurse’s PRIORITY?
A. Reinforce the surgical dressing with additional sterile gauze and reassess in 15 minutes
B. Notify the surgeon immediately
C. Assess urinary output via Foley catheter
D. Reassure the patient that restlessness is expected after surgery
Correct answer: B - notify surgeon immediately
Rationale: The patient is exhibiting signs of hemorrhagic shock. Reinforcing dressings and reassessing delays care. The nurse must call the surgeon immediately after rapid assessment.
A patient with congestive heart failure is receiving furosemide (Lasix) IV. The patient’s morning labs are:
K⁺: 2.7 mEq/L
Na⁺: 139 mEq/L
BUN: 15 mg/dL
Creatinine: 0.9 mg/dL
Which order should the nurse QUESTION?
A. Start IV potassium chloride infusion
B. Continue furosemide 40 mg IV every 8 hrs
C. Place patient on cardiac monitoring
D. Administer oral potassium supplements
Correct answer: B - continue furosemide 40mg IV every 8 hours
Rationale: Furosemide (Lasix) is a loop diuretic and it’s potassium-wasting, so it commonly causes hypokalemia. That’s why in the scenario with a K⁺ of 2.7 mEq/L, the safest action is to hold further furosemide and correct the potassium first. The provider may switch this patient to a potassium sparing diuretic such as spironolactone.
The nurse is caring for four patients on a medical-surgical unit. Which task is MOST appropriate to delegate to an experienced UAP (unlicensed assistive personnel)?
A. Feeding a patient with new onset dysphagia following a stroke
B. Obtaining orthostatic vital signs for a patient with a history of falls
C. Teaching a patient with diabetes how to self-administer insulin
D. Assessing lung sounds on a patient with pneumonia
Correct answer: B - obtaining orthostatics for a patient with a history of falls
Rationale: UAP can collect routine, stable data (like vitals). Dysphagia patients, ESPECIALLY new onset, require RN due to aspiration risk. Teaching and assessment are always the RN’s responsibility.
A 72-year-old patient with a history of atrial fibrillation has been on warfarin (Coumadin) for 6 months to reduce the risk of stroke. The patient presents today for a routine follow-up appointment. The nurse reviews the lab results:
INR: 6.2
Hgb: 11.2 g/dL (slightly low)
Hct: 33%
Vital signs: BP 118/64, HR 78, RR 16, Temp 98.4°F
The patient reports, “I noticed some bruises on my arms and gums bleeding when I brush my teeth, but otherwise I feel fine.”
Which nursing action is MOST appropriate?
A. Administer warfarin as ordered since the patient is asymptomatic
B. Hold the warfarin dose and anticipate an order for vitamin K
C. Instruct the patient to increase dietary intake of green leafy vegetables immediately
D. Document the finding and recheck the INR at the next appointment
Correct answer: B - hold the warfarin dose and anticipate an order for Vitamin K
Rationale:
The therapeutic INR for warfarin is usually 2.0–3.0.
An INR of 6.2 is dangerously high, placing the patient at significant risk for spontaneous bleeding.
Clinical signs (bruising, gum bleeding) confirm this.
The safest action is to hold warfarin and anticipate reversal with vitamin K.
Increasing vitamin K intake (C) might help long-term but is not appropriate as an immediate intervention.
Documenting only (D) or giving the drug (A) places the patient at risk for severe hemorrhage.
The nurse is caring for four medical-surgical patients during morning rounds. Which patient should the nurse assess first?
A. A 64-year-old with chronic COPD on 2 L O₂ NC, reporting shortness of breath with exertion, SpO₂ 90%, using accessory muscles but speaking in full sentences.
B. A 48-year-old post-cholecystectomy reporting abdominal pain 8/10 despite recent IV morphine. Abdomen is soft, no guarding or rigidity noted.
C. A 72-year-old post-total hip replacement with new onset confusion this morning. Vitals: BP 110/68, HR 96, SpO₂ 88% on room air.
D. A 55-year-old with diabetes mellitus who received insulin 30 minutes ago and now reports feeling “shaky” and lightheaded. Current blood glucose = 48 mg/dL.
Correct answer: D - A 55-year-old with diabetes mellitus who received insulin 30 minutes ago and now reports feeling “shaky” and lightheaded. Current blood glucose = 48 mg/dL.
Rationale: Symptomatic hypoglycemia can rapidly progress to seizures, coma, or death so immediate intervention required. Confusion with SpO₂ 88% is concerning (possible hypoxia/embolus), but airway is not yet failing — this is a close second priority.
COPD with baseline O₂ sat ~90% is chronic/stable unless decompensating (still speaking in full sentences). Post-op pain is expected and not immediately life-threatening in the absence of peritonitis/bleeding signs.
Life-Threatening: Hypoxemia is a critical condition and is a high-priority concern, often considered under the ABC's (Airway, Breathing, Circulation), but the body has some reserves.
Less Rapidly Fatal: While severe hypoxemia is also life-threatening, it generally allows for a slightly longer time for assessment and intervention compared to severe hypoglycemia.
A patient with a chest tube following a pneumothorax suddenly develops severe dyspnea, tracheal deviation to the left, absent breath sounds on the right, and jugular vein distension.
What is the nurse’s PRIORITY action?
A. Assess oxygen saturation with a pulse oximeter
B. Call the rapid response team and prepare for needle decompression
C. Clamp the chest tube to prevent further air entry
D. Place the patient in high Fowler’s position for comfort
Correct answer: B - call RRT and prepare for needle decompression
Rationale: This is a tension pneumothorax which is life-threatening. Immediate intervention is needle decompression/chest tube replacement. Calling rapid response and preparing supplies is priority. The other options delay care.
A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?
A. Notify the patient's provider
B. Complete a medication error form
C. Check the patient's vital signs
D. Administer the medication to the correct patient
Correct answer: C - check vitals
Rationale: The first action the nurse should take using the nursing process is to assess the client. The nurse should know that the action of nifedipine is to lower blood pressure. Immediately upon realizing the error, the nurse should check the client's vital signs (especially the client's blood pressure) to ensure that the client is not hypotensive as a result. Only after ensuring that the client is safe and has stable vital signs should the nurse take other actions.
The charge nurse is assigning patients. Which patient is MOST appropriate for the LPN to care for?
A. A newly admitted patient with GI bleeding who requires initial assessment and plan of care
B. A patient with heart failure who requires IV push furosemide
C. A stable post-operative patient who needs wound care and oral antibiotics
D. A patient with diabetic ketoacidosis on an insulin drip requiring titration
Correct answer: C - stable post operative patient who needs wound care and oral antibiotics
Rationale: LPNs can perform routine care on stable patients, including dressing changes and administering oral meds. RNs handle new admissions, unstable/critical patients, and IV push meds (depending on state).
A 28-year-old with a T4 spinal cord injury (stable and in the rehab unit) suddenly reports a pounding headache, facial flushing, and sweating above the level of injury. Vitals: BP 224/118, HR 48, RR 16, SpO₂ 98% RA. The patient has an indwelling urinary catheter, and morning bowel program was delayed.
What is the nurse’s FIRST action?
A. Place the patient upright (high Fowler’s) and assess for bladder distension/catheter kinks
B. Lay the patient flat and apply a warming blanket
C. Administer IV hydralazine immediately
D. Notify the provider and wait for new orders
Correct answer: A - Place the patient upright (high Fowler’s) and assess for bladder distension/catheter kinks
Rationale: These are classic s/s of autonomic dysreflexia: severe HTN, bradycardia, headache, flushing in a patient with SCI at/above T6. First lower BP non-pharmacologically by sitting upright and eliminating triggers—most commonly a full bladder or catheter obstruction. If unresolved, then consider rapid-acting antihypertensives and notify the provider.
Supine worsens HTN; warming is irrelevant.
Meds may be needed after immediate non-drug measures and removal of the stimulus.
Calling first delays the corrective action you can and should do now.