1
A. Encourage coughing and deep breathing
B. Position the client in high-Fowler’s
C. Obtain a sputum culture
D. Administer oral fluids
Correct Answer: B — Position the client in high-Fowler’s
Rationale: Airway and breathing are the priority (ABCs). High-Fowler’s maximizes lung expansion and decreases work of breathing before other interventions.
6. A client receiving oxygen via nasal cannula at 2 L/min has COPD. Why is this flow rate appropriate?
A. Prevents oxygen toxicity
B. Maintains adequate oxygenation without suppressing drive
C. Eliminates need for ABGs
D. Prevents CO₂ retention entirely
Correct Answer: B — Maintains adequate oxygenation without suppressing drive
Rationale: Patients with COPD rely on hypoxic drive. Low-flow oxygen prevents respiratory depression.
11. A patient with tuberculosis should be placed on which precaution?
A. Droplet
B. Contact
C. Airborne
D. Standard
Correct Answer: C — Airborne
Rationale: Tuberculosis spreads via airborne droplets and requires a negative-pressure room and N95 mask.
16. A client with a low platelet count is at greatest risk for which complication?
A. Infection
B. Hypoxia
C. Bleeding
D. Fluid overload
Correct Answer: C — Bleeding
Rationale: Low platelets impair clot formation, significantly increasing bleeding risk.
21. A patient with sickle cell disease reports severe pain. What is the nurse’s priority action?
A. Encourage ambulation
B. Administer prescribed pain medication
C. Apply cold compresses
D. Restrict fluids
Correct Answer: B — Administer prescribed pain medication
Rationale: Severe pain during a sickle cell crisis must be managed promptly to reduce stress and oxygen demand.
2. A patient with pneumonia has crackles in the lower lobes and an oxygen saturation of 88%. Which nursing diagnosis is the priority?
A. Impaired gas exchange
B. Risk for infection
C. Activity intolerance
D. Ineffective airway clearance
Correct Answer: A — Impaired gas exchange
Rationale: Low oxygen saturation and crackles indicate impaired oxygen exchange at the alveolar level, making this the priority nursing diagnosis.
7. Which finding indicates improvement in a patient being treated for pneumonia?
A. Increased respiratory rate
B. Productive cough with yellow sputum
C. Oxygen saturation of 95%
D. Presence of crackle
Correct Answer: C — Oxygen saturation of 95%
Rationale: Improved oxygenation indicates effective treatment and improved gas exchange.
12. Which symptom is most concerning in a patient with a pulmonary embolism?
A. Sudden shortness of breath
B. Low-grade fever
C. Productive cough
D. Gradual fatigue
Correct Answer: A — Sudden shortness of breath
Rationale: Sudden dyspnea is a hallmark sign of pulmonary embolism and requires immediate attention.
17. Which nursing intervention is priority for a patient with neutropenia?
A. Encourage increased fluids
B. Implement infection precautions
C. Monitor oxygen saturation
D. Limit ambulation
Correct Answer: B — Implement infection precautions
Rationale: Neutropenia increases infection risk; preventing exposure is the priority.
22. Which intervention should the nurse include when caring for a patient with anemia?
A. Encourage iron-rich foods
B. Restrict oxygen
C. Limit rest periods
D. Avoid vitamin C
Correct Answer: A — Encourage iron-rich foods
Rationale: Iron supports hemoglobin production and is essential in managing anemia.
3. The nurse is caring for a patient with a respiratory rate of 8 breaths/min. Which action follows ABC prioritization?
A. Check temperature
B. Assess level of consciousness
C. Prepare to assist with ventilation
D. Document findings
Correct Answer: C — Prepare to assist with ventilation
Rationale: A respiratory rate of 8 is dangerously low. Breathing is compromised and must be addressed immediately per ABCs.
8. A patient with a chest tube suddenly becomes restless and short of breath. What should the nurse do first?
A. Notify the provider
B. Check the chest tube system
C. Administer pain medication
D. Increase IV fluids
Correct Answer: B — Check the chest tube system
Rationale: Sudden respiratory distress may indicate a chest tube malfunction. Assess equipment first before notifying the provider.
13. The nurse notes diminished breath sounds on one side after surgery. What is the priority nursing action?
A. Encourage use of incentive spirometer
B. Obtain a chest x-ray
C. Increase IV fluids
D. Administer antibiotics
Correct Answer: A — Encourage use of incentive spirometer
Rationale: Diminished breath sounds post-op often indicate atelectasis. Incentive spirometry promotes lung expansion.
18. A patient receiving warfarin therapy requires monitoring of which lab?
A. aPTT
B. Platelets
C. INR
D. Hemoglobin
Correct Answer: C — INR
Rationale: Warfarin affects clotting time measured by INR; maintaining therapeutic range is critical.
23. A patient with a hematologic disorder is short of breath and tachycardic. Which nursing diagnosis takes priority?
A. Risk for infection
B. Impaired gas exchange
C. Activity intolerance
D. Risk for bleeding
Correct Answer: B — Impaired gas exchange
Rationale: Shortness of breath and tachycardia indicate compromised oxygen delivery, making this the priority diagnosis.
4. A client with asthma reports chest tightness and wheezing. Which medication should the nurse expect to administer first?
A. Inhaled corticosteroid
B. Short-acting bronchodilator
C. Oral leukotriene inhibitor
D. Antibiotic
Correct Answer: B — Short-acting bronchodilator
Rationale: Rescue inhalers rapidly open airways and are always given first during acute asthma symptoms.
9. Which assessment finding suggests a patient is experiencing respiratory acidosis?
A. Shallow respirations
B. Rapid deep breathing
C. Tingling of fingers
D. Fruity breath odor
Correct Answer: A — Shallow respirations
Rationale: Hypoventilation leads to CO₂ retention, causing respiratory acidosis.
14. A patient with anemia reports fatigue and dizziness. Which assessment finding supports this diagnosis?
A. Hypertension
B. Pale conjunctiva
C. Bounding pulse
D. Increased appetite
Correct Answer: B — Pale conjunctiva
Rationale: Pallor is a classic sign of decreased red blood cell count and oxygen-carrying capacity.
19. The nurse suspects internal bleeding in a post-operative patient. Which sign is most concerning?
A. Increased urine output
B. Decreasing blood pressure
C. Warm skin
D. Decreased pain
Correct Answer: B — Decreasing blood pressure
Rationale: Hypotension may indicate internal bleeding and potential shock.
24. Which sign indicates a transfusion reaction and requires immediate action?
A. Mild headache
B. Low-grade fever
C. Chills and dyspnea
D. Slight nausea
Correct Answer: C — Chills and dyspnea
Rationale: These are signs of an acute transfusion reaction and require immediate cessation of the transfusion.
5. Which assessment finding in a patient with hypoxia requires immediate intervention?
A. Restlessness
B. Cyanosis of lips
C. Mild tachycardia
D. Fatigue
Correct Answer: B — Cyanosis of lips
Rationale: Cyanosis is a late and serious sign of hypoxia requiring immediate intervention.
10. When teaching incentive spirometry, which instruction is most important?
A. Exhale forcefully after inhalation
B. Use the device once per shift
C. Inhale slowly and deeply
D. Lie flat during use
Correct Answer: C — Inhale slowly and deeply
Rationale: Slow, deep inhalation maximizes alveolar expansion and prevents atelectasis.
15. Which lab value is most important to monitor in a patient with active bleeding?
A. White blood cell count
B. Platelet count
C. Hemoglobin and hematocrit
D. INR only
Correct Answer: C — Hemoglobin and hematocrit
Rationale: These values directly reflect blood loss and oxygen-carrying capacity.
20. Which finding indicates a patient may be experiencing hypovolemic shock related to blood loss?
A. Bradycardia
B. Narrow pulse pressure
C. Cool, clammy skin
D. Elevated blood pressure
Correct Answer: C — Cool, clammy skin
Rationale: This is a classic sign of hypovolemic shock due to decreased perfusion.
25. The nurse applies ABCs when caring for a patient with severe anemia. Which intervention comes first?
A. Administer iron supplements
B. Assess airway and oxygenation
C. Obtain dietary history
D. Educate on medication adherence
Correct Answer: B — Assess airway and oxygenation
Rationale: Severe anemia affects oxygen delivery; airway and breathing take priority under ABCs