Safety & Prioritization
You receive report on four patients. Which patient should you assess first?
A. A patient with pneumonia whose temperature is 100.8°F (38.2°C)
B. A postoperative patient reporting incisional pain of 7/10
C. A patient with COPD who is newly restless and has an SpO₂ of 88%, down from 94%
D. A patient with diabetes whose blood glucose is 250 mg/dL
Answer: C — The patient with COPD.
Rationale: A new change in oxygenation with restlessness may indicate worsening hypoxemia. Assess respiratory status immediately rather than assuming the finding is baseline COPD.
A patient with heart failure develops worsening dyspnea when lying flat, bilateral crackles, and pink, frothy sputum. Which complication should the nurse suspect?
A. Pulmonary edema
B. Pneumothorax
C. Atelectasis
D. Pulmonary embolism
A — Pulmonary edema.
Rationale: Orthopnea, crackles, and pink frothy sputum suggest fluid accumulation in the alveoli and require urgent intervention.
A patient scheduled to receive metoprolol has a HR of 48/min and reports dizziness. What should the nurse do first?
A. Give the medication because it is scheduled
B. Hold the dose, assess the patient, and notify the provider according to protocol
C. Give half the prescribed dose without an order
D. Encourage the patient to ambulate
B — Hold, assess, and notify.
Rationale: Metoprolol can further lower heart rate and blood pressure. Symptomatic bradycardia warrants assessment and clarification before administration.
A patient's potassium is 6.3 mEq/L. Which assessment finding would be most concerning?
A. Mild thirst
B. Peaked T waves on the ECG
C. Increased appetite
D. Warm, dry skin
B — Peaked T waves.
Rationale: Hyperkalemia can alter cardiac conduction and cause fatal dysrhythmias. This result and ECG finding require immediate escalation and treatment.
A patient newly diagnosed with heart failure says, “I'm scared. What if I never feel normal again?” Which response is best?
A. “I understand, but no need to worry. Heart failure is very manageable.”
B. “Many people have heart failure and live normal lives.”
C. “It sounds like you're worried about how this will affect your life. What concerns you most?”
D. “Let's focus on learning your medications, that will likely help you out.”
C — "It sounds like you're worried about how this will affect your life..." Acknowledge feelings and invite exploration.
Rationale: This response validates the emotion without making promises and encourages the patient to share specific fears.
Which task is most appropriate for the RN to delegate to an experienced nursing assistant for a stable medical-surgical patient?
A. Assess a patient who reports new dizziness when standing
B. Teach a patient how to use an incentive spirometer
C. Obtain routine vital signs on a stable patient
D. Evaluate whether a PRN analgesic relieved pain
C — Obtain routine vital signs.
Rationale: Routine data collection on a stable patient may be delegated to trained assistive personnel. Assessment, teaching, and evaluation remain RN responsibilities.
A patient with suspected appendicitis reports that severe right lower quadrant pain suddenly disappeared. Shortly afterward, the patient develops generalized abdominal pain, guarding, and a fever. What complication is most concerning?
A. Resolution of the inflammation
B. Bowel obstruction
C. Appendiceal rupture with peritonitis
D. Gastroesophageal reflux
C — Appendiceal rupture with peritonitis.
Rationale: Sudden pain relief followed by diffuse pain and guarding can signal rupture and spreading peritoneal inflammation. This requires urgent surgical evaluation.
A patient takes lisinopril and spironolactone. Which laboratory result is most concerning before administering the scheduled medications?
A. Sodium 139 mEq/L
B. Potassium 5.8 mEq/L
C. Calcium 9.2 mg/dL
D. Glucose 108 mg/dL
B — Potassium 5.8 mEq/L.
Rationale: Both medications can increase potassium. Hyperkalemia can cause life-threatening dysrhythmias, so the nurse should promptly assess, verify the result as appropriate, and notify the provider before administering the medications.
A patient's WBC count rises from 9,000/mm³ to 17,500/mm³ over 24 hours. The patient is also newly confused and has a HR of 118/min. Which interpretation is best?
A. The WBC count alone confirms sepsis
B. The trend and clinical changes raise concern for worsening infection and possible sepsis, requiring prompt assessment
C. Confusion is expected with every elevated WBC count
D. The nurse should wait until the WBC reaches 20,000/mm³
B — The trend and changes raise concern for sepsis requiring prompt assessment.
Rationale: No single WBC value confirms or excludes sepsis. Acute mental-status changes and tachycardia in a patient with possible infection are concerning and warrant urgent evaluation.
A patient with hypertension refuses the prescribed medication, saying, “I feel fine. I don't need pills.” What should the nurse say first?
A. “If you don’t take it, you'll likely have a stroke.”
B. “This is an example of noncompliance. Please take the pills.”
C. “Can you tell me more about what concerns you about taking this medication?”
D. “No worries, I will document your refusal.”
C — Explore the patient's concerns.
Rationale: An open-ended, nonjudgmental question can reveal barriers such as side effects, cost, or misunderstanding. Education is more effective when tailored to the patient's concerns.
Six hours after abdominal surgery, a patient becomes pale and diaphoretic. HR is 124/min, BP is 86/50 mmHg, and the dressing has a small amount of drainage. What is the nurse's priority action?
A. Administer the prescribed PRN opioid
B. Reassess in 30 minutes to determine the trend
C. Encourage oral fluids
D. Activate the appropriate emergency response and initiate immediate assessment and support
D — Initiate emergency assessment and support.
Rationale: Hypotension, tachycardia, pallor, and diaphoresis suggest possible shock, including occult bleeding. Do not be reassured by minimal visible drainage.
A patient has had vomiting and diarrhea for three days. Urine output is declining, BUN and creatinine are elevated, and the patient has dry mucous membranes and orthostatic hypotension. Which cause of acute kidney injury is most likely?
A. Prerenal injury from reduced renal perfusion
B. Postrenal injury from urinary obstruction
C. Intrinsic renal injury from glomerular damage
D. Chronic kidney disease from long-term hypertension
A — Prerenal acute kidney injury.
Rationale: Gastrointestinal fluid loss and signs of volume depletion suggest reduced blood flow to the kidneys. The nurse should promptly assess perfusion, urine output, and the need for prescribed fluid replacement.
A patient taking warfarin reports black, tarry stools and new dizziness. What is the nurse's priority response?
A. Reassure the patient that dark stools are expected
B. Tell the patient to increase dietary vitamin K and continue the medication
C. Assess for bleeding and hemodynamic instability, hold further doses pending urgent clinical direction, and escalate care
D. Recommend an over-the-counter antacid
C — Assess for bleeding and urgently escalate suspected bleeding.
Rationale: Melena and dizziness suggest possible gastrointestinal bleeding. The patient needs urgent assessment, including vital signs and appropriate labs such as CBC and INR.
A patient with prolonged vomiting has these results: pH 7.49, HCO₃⁻ 32 mEq/L, and PaCO₂ 46 mmHg. Which acid-base imbalance is present?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
D — Metabolic alkalosis.
Rationale: The pH is alkalemic and bicarbonate is elevated, indicating a primary metabolic process. The slightly elevated PaCO₂ is consistent with respiratory compensation. Vomiting causes gastric acid loss.
A family member says, “Nobody here cares! We've been waiting forever, and my father is getting worse!” What is the best initial response?
A. “It’s not that we don’t care, we've just been very busy.”
B. “I can see how worried and frustrated you are. Tell me what changes you've noticed in your father.”
C. “I can help you if you calm down, please.”
D. “The provider will come as soon as possible.”
B — “I can see how worried and frustrated you are. Tell me what changes you've noticed in your father.” -- Acknowledge emotion and assess the concern.
Rationale: The nurse acknowledges the emotion without becoming defensive and gathers information about a possible clinical change. The father's condition must be assessed promptly if deterioration is suspected.
Four call lights go off simultaneously. Which patient requires the most immediate intervention?
A. A patient with heart failure who has bilateral ankle edema
B. A patient with diabetes who is diaphoretic, confused, and has a glucose of 48 mg/dL
C. A patient with a suspected DVT reporting calf pain
D. A patient with a UTI reporting urinary frequency and burning
B — The patient with symptomatic hypoglycemia.
Rationale: Severe hypoglycemia can rapidly cause seizures, loss of consciousness, and permanent injury. Check airway and ability to swallow, then treat immediately using the appropriate protocol. Do not give oral carbohydrates to a patient who cannot swallow safely.
On postoperative day one after abdominal surgery, a patient develops sudden dyspnea, pleuritic chest pain, HR 128/min, and SpO₂ 86%. Breath sounds are present bilaterally. Which complication should the nurse suspect?
A. Postoperative ileus
B. Pulmonary embolism
C. Wound dehiscence
D. Urinary retention
B — Pulmonary embolism.
Rationale: Sudden dyspnea, pleuritic pain, tachycardia, and hypoxemia after surgery are concerning for PE. Activate urgent evaluation and support oxygenation; do not delay to complete a routine assessment.
A nurse is preparing to administer furosemide to a patient with heart failure. The patient's morning labs show a potassium level of 2.9 mEq/L. The patient also reports new muscle weakness. What is the nurse's best action?
A. Administer the medication because it will reduce the patient's fluid overload.
B. Hold the medication, assess the patient, and promptly notify the provider.
C. Administer the medication with a full glass of water to prevent dehydration.
D. Encourage the patient to eat potassium-rich foods and administer the medication as scheduled.
B — Hold med, assess, notify provider.
Rationale: Furosemide is a loop diuretic that can increase potassium loss. A potassium level of 2.9 mEq/L indicates hypokalemia, which can cause muscle weakness and potentially dangerous cardiac dysrhythmias. The nurse should assess the patient, withhold the dose pending prompt clarification, and notify the provider.
A patient on postoperative day two has a hemoglobin decrease from 12.4 to 8.1 g/dL, HR 122/min, BP 94/56 mmHg, and increasing weakness. What is the most appropriate interpretation?
A. Normal postoperative hemodilution that needs no follow-up
B. Possible significant blood loss with hemodynamic compromise
C. Iron-deficiency anemia caused by poor dietary intake over two days
D. A laboratory finding unrelated to the patient's vital signs
B — Possible significant blood loss.
Rationale: A substantial hemoglobin drop combined with tachycardia, hypotension, and weakness raises concern for bleeding and impaired perfusion. Escalate immediately rather than waiting for another routine CBC.
A patient with COPD says, “I know smoking is bad, but it's the only thing that helps me relax.” Which response best supports motivational interviewing?
A. “Smoking helps you cope with stress, and you're also aware of its effects on your breathing. What do you think about those two things?”
B. “Quitting immediately will help you get better.”
C. “You already know smoking is harmful, so why keep doing it?”
D. “I'll give you a pamphlet on smoking cessation.”
A — "Smoking helps you cope with stress, and you're also aware of its effects on your breathing. What do you think about those two things?” -- Reflect ambivalence without judgment.
Rationale: Reflecting both sides of the patient's experience encourages the patient to explore their own reasons for change instead of feeling lectured or pressured.
A patient admitted with pneumonia was alert an hour ago. Now the patient is difficult to arouse, RR 8/min, SpO₂ 84%, and BP 92/58 mmHg. What is the nurse's best immediate response?
A. Obtain a complete set of routine vital signs and document the change
B. Call the provider, then wait for orders before intervening
C. Activate the rapid response/emergency system, support airway and breathing, and provide oxygen/ventilatory support as indicated
D. Elevate the head of the bed and return in 15 minutes
C — Activate emergency assistance and support ABCs.
Rationale: Bradypnea, depressed consciousness, and hypoxemia indicate life-threatening respiratory compromise. Emergency response, airway support, oxygenation, and ventilation take priority over routine documentation or waiting for orders.
A patient with diabetes presents with abdominal pain, vomiting, deep rapid respirations, fruity breath, glucose 460 mg/dL, and positive serum ketones. Which interpretation best explains these findings?
A. Hypoglycemia causing adrenergic symptoms
B. Hyperosmolar hyperglycemic state without significant ketosis
C. Diabetic ketoacidosis with metabolic acidosis
D. Respiratory alkalosis caused by anxiety
C — Diabetic ketoacidosis (DKA).
Rationale: Ketones and deep, rapid Kussmaul respirations point toward metabolic acidosis from DKA. This is an emergency requiring prompt evaluation, IV fluids, insulin when appropriate, and close potassium monitoring.
A patient with type 1 diabetes is NPO for a procedure. The morning medication list includes basal insulin and rapid-acting insulin scheduled with breakfast. The patient's glucose is 112 mg/dL. Which action is safest?
A. Hold every type of insulin because the patient is NPO
B. Administer both insulins at their usual doses because the glucose is normal
C. Clarify the insulin orders and coordinate glucose monitoring and appropriate insulin coverage; do not automatically omit basal insulin or give meal insulin without a meal
D. Give rapid-acting insulin to prevent hyperglycemia during fasting
C — Clarify insulin orders and coordinate. Individualize the plan and clarify orders.
Rationale: Patients with type 1 diabetes generally need basal insulin even while NPO to prevent ketosis and DKA. Prandial insulin usually needs to be withheld or adjusted when a meal is not eaten, while glucose monitoring and prescribed correction coverage continue as indicated.
A patient with chronic kidney disease has potassium 6.7 mEq/L. The patient denies symptoms, and the first ECG appears unchanged. What should the nurse do?
A. Document the result and repeat the test at the next scheduled draw
B. Encourage potassium-rich foods because the patient is asymptomatic
C. Promptly escalate the critical result, assess the patient, and prepare for urgent treatment and cardiac monitoring
D. Wait for muscle weakness before notifying the provider
C — Urgent escalation and treatment readiness.
Rationale: Severe hyperkalemia may be asymptomatic, and a normal-looking ECG does not make it safe. Follow critical-result protocols, assess promptly, and anticipate emergency treatment.
A patient with advanced cancer says, “My family keeps telling me to fight, but I'm exhausted. I don't know if I want more treatment.” What is the nurse's best response?
A. “It sounds like your family wants what's best for you.”
B. “Don’t give up hope; there are always more options.”
C. “That’s understandable and would best be discussed with your oncologist.”
D. “It sounds like you're exhausted and feeling pulled in different directions. What matters most to you as you consider your options?”
D — Explore the patient's values and goals.
Rationale: This response acknowledges distress and supports autonomy. The nurse can help the patient clarify goals, communicate with the oncology team, and access palliative care or a goals-of-care discussion without steering the decision.