Random 1
A nurse is assessing a patient with Cushing’s syndrome. Which finding should the nurse expect?
A. Weight loss and sunken eyes
B. Buffalo hump and moon face
C. Decreased facial hair in women
D. Thin trunk and enlarged extremities
B
Which vital sign change is most likely in a patient with moderate anemia?
A. Bradycardia
B. Slow, deep respirations
C. Tachycardia
D. Low temperature
Correct Answer: C
Rationale:
Heart beats faster (tachycardia) to compensate for low oxygen.
A patient arrives in the ED with BP 212/118 mmHg, severe headache, and blurred vision. Which action is the priority?
A. Administer IV antihypertensive medication
B. Place the patient in Trendelenburg position
C. Recheck the blood pressure in 1 hour
D. Provide water to decrease dehydration
Correct Answer: A
Rationale:
BP >180/120 with symptoms = hypertensive emergency.
Immediate IV antihypertensive therapy is needed to prevent organ damage.
A nurse is teaching a newly diagnosed patient with type 2 diabetes about recognizing signs of hypoglycemia. Which statement by the patient indicates a need for further teaching?
A. “If my blood sugar gets too low, I might feel shaky or sweaty.”
B. “Confusion or difficulty thinking can happen when my sugar drops.”
C. “If I begin to feel hungry or dizzy, I should check my blood sugar.”
D. “High blood sugar usually causes symptoms of sweating and tremors.”
Answer D. “High blood sugar usually causes symptoms of sweating and tremors.”
A patient with HF is taking digoxin. Which finding requires immediate intervention?
A. Heart rate 58 bpm
B. Potassium level 3.0 mEq/L
C. Fatigue
D. Weight gain of 1 lb in 24 hours
Correct Answer: B
Rationale:
Low potassium (hypokalemia) greatly increases the risk of digoxin toxicity.
HR < 60 usually means hold the dose, but the potassium level is the more urgent problem.
A nurse is caring for a patient with type 1 diabetes who is prescribed regular insulin and NPH insulin. Which action by the nurse is correct?
A. Draw up the NPH insulin first, then the regular insulin
B. Draw up the regular insulin first, then the NPH insulin
C. Administer the NPH insulin IV push
D. Roll the regular insulin vial between the palms before drawing it up
Correct Answer: B
The nurse is teaching a patient who is prescribed hydrochlorothiazide (HCTZ). Which instruction is appropriate?
A. “Take this medication at bedtime to help relaxation.”
B. “You may need to increase potassium-rich foods.”
C. “Avoid all dairy products while taking this medication.”
D. “This medication may cause your heart rate to slow down.”
Correct Answer: B
Rationale:
HCTZ can cause hypokalemia, so increasing foods like bananas, oranges, and potatoes is important.
A patient asks the nurse what anemia means. Which response is most accurate?
A. “You don’t have enough white blood cells.”
B. “Your blood does not have enough hemoglobin to carry oxygen.”
C. “Your blood pressure is too low.”
D. “Your body is making too many red blood cells.”
Correct Answer: B
Rationale:
Anemia = low hemoglobin or RBCs → decreased oxygen-carrying capacity.
A patient with chronic HF presents with increased shortness of breath, frothy pink sputum, and anxiety. Which action is the priority?
A. Insert a Foley catheter
B. Elevate the head of the bed
C. Weigh the patient
D. Administer a PRN potassium supplement
Correct Answer: B
Rationale:
These signs indicate acute pulmonary edema.
Sit the patient upright immediately to improve oxygenation, then give oxygen and diuretics.
A client with migraines is prescribed propranolol. Which statement shows the need for further teaching?
A. “This medication helps prevent migraines.”
B. “I should not stop this medication suddenly.”
C. “I may not notice benefits for several weeks.”
D. “I will take this medication only when a migraine starts.”
Correct Answer: D
Rationale: Propranolol is a preventive medication, taken daily—not during an attack.
After a seizure, the nurse should:
A. Give food immediately
B. Place the patient in the recovery (side-lying) position
C. Start CPR
D. Force the patient to wake up
Correct Answer: B
Rationale:
Side-lying helps maintain an open airway and prevents aspiration
A 42-year-old woman arrives at the clinic with rapid breathing, numbness around her mouth, and tingling in her fingers after a panic attack.
ABG results:
pH: 7.52
PaCO₂: 28 mmHg
HCO₃⁻: 24 mEq/L
Which of the following is the correct interpretation of this ABG?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Partially compensated respiratory alkalosis
D. Fully compensated respiratory alkalosis
Respiratory alkalosis
The nurse is assessing a patient with asthma. Which finding would be considered an early sign of an asthma exacerbation?
A. Bradypnea
B. Wheezing
C. Absent breath sounds
D. Cyanosis
Correct Answer: B
Rationale:
Wheezing indicates narrowed airways and is an early sign.
Absent breath sounds and cyanosis are late, life-threatening signs.
A patient taking sumatriptan for acute migraine attacks should be taught to report which finding immediately?
A. Flushing
B. Mild dizziness
C. Chest pain
D. Tingling of fingers
Correct Answer: C
Rationale: Triptans cause vasoconstriction; chest pain can indicate coronary vasospasm and is an emergency.
The nurse is reviewing the chart of a patient with severe COPD. Which finding should the nurse expect?
A. Weight gain
B. Decreased RBC count
C. Clubbing of fingers
D. Hyperactive deep tendon reflexes
Correct Answer: C
Rationale:
Chronic hypoxia in COPD can lead to clubbing and polycythemia (↑ RBCs). Weight loss is common due to increased work of breathing.
The nurse is teaching a patient newly diagnosed with hypertension. Which statement indicates the need for further teaching?
A. “I will limit my sodium to 1,500–2,000 mg per day.”
B. “I should exercise at least 150 minutes each week.”
C. “I can stop taking my medication once my blood pressure is normal.”
D. “Losing weight can help lower my blood pressure.”
Correct Answer: C
Rationale:
HTN is chronic. Medication should not be stopped when BP improves—this could cause rebound hypertension.
A patient taking levodopa-carbidopa asks why they need the medication. The best response is:
A. “It helps increase dopamine levels in your brain.”
B. “It prevents headaches.”
C. “It increases serotonin in the brain.”
D. “It helps cure the disease.
Correct Answer: A
Rationale:
Parkinson’s = low dopamine → levodopa increases dopamine.
During a generalized tonic–clonic seizure, the nurse’s priority is to:
A. Hold the patient down
B. Place a tongue blade in the mouth
C. Protect the patient from injury
D. Give oral medication
Correct Answer: C
Rationale:
Do not restrain or put objects in the mouth. Ensure safety.
A patient with type 1 diabetes arrives with fruity breath, Kussmaul respirations, and nausea. Which lab finding supports a diagnosis of diabetic ketoacidosis (DKA)?
A. Serum pH 7.38
B. Blood glucose 160 mg/dL
C. Serum bicarbonate 12 mEq/L
D. Potassium 3.8 mEq/L
Correct Answer: C
Rationale: DKA involves metabolic acidosis, reflected by low bicarbonate (< 15 mEq/L) and low pH
The nurse is teaching a patient with HF about furosemide. Which statement indicates a need for further teaching?
A. “I will weigh myself every morning.”
B. “I will call my provider if I feel dizzy.”
C. “I should increase foods high in potassium.”
D. “I will take my medication at bedtime.”
Correct Answer: D
Rationale:
Diuretics should be taken in the morning to prevent nocturia.
Dizziness may indicate dehydration; potassium is important with loop diuretics.
Which symptom is characteristic of Parkinson’s disease?
A. Muscle paralysis
B. Tremors at rest
C. High fever
D. Sudden confusion
Correct Answer: B
Rationale:
Parkinson’s classic signs: resting tremor, bradykinesia, rigidity, shuffling gait.
A patient with COPD arrives in the ED complaining of increasing dyspnea and productive cough. Oxygen saturation is 86% on room air. What is the priority nursing action?
A. Increase oxygen to 4 L/min via nasal cannula
B. Encourage the patient to drink fluids
C. Teach pursed-lip breathing
D. Obtain a sputum culture
Correct Answer: A
Rationale:
During an exacerbation with hypoxemia, the priority is to improve oxygenation. Oxygen may be safely titrated in COPD patients to maintain SpO₂ 88–92%.
A patient recently started on lisinopril reports swelling of the lips and tongue. What is the priority nursing action?
A. Hold the next dose and document the findings
B. Notify the healthcare provider immediately
C. Offer the patient ice chips for comfort
D. Ask the patient about their diet
Correct Answer: B
Rationale:
Lip/tongue swelling = angioedema, a life-threatening reaction.
Immediate provider notification and airway management are needed.
A patient with chronic lower back pain says their pain is “tolerable” but always present. What is the best nursing response?
A. “Let’s talk about non-pharmacological ways to help manage your pain.”
B. “You should avoid taking pain medication daily.”
C. “Chronic pain usually means something is seriously wrong.”
D. “Try to ignore the pain; it will get better.”
Correct Answer: A
Rationale: Chronic pain management includes pharmacologic and non-drug strategies.
A patient using a PCA pump for morphine reports 9/10 pain. The family asks if they can push the PCA button to help. What is the nurse’s best response?
A. “Yes, as long as the patient tells you they are in pain.”
B. “No, only the patient should push the PCA button.”
C. “It is fine if you push it when the patient is asleep.”
D. “Let me increase the dose first.”
Correct Answer: B
Rationale: Only the patient should push the PCA button to avoid oversedation.