Cardiac
The nurse is caring for a 72-year-old client admitted with acute decompensated heart failure. The client is receiving IV furosemide and has a new prescription for digoxin. Current assessment: BP 102/64, HR 58, RR 22, crackles in lower lobes, potassium 3.2 mEq/L, and the client reports seeing “yellowish halos.”
Which action should the nurse take first?
A. Hold the digoxin and notify provider
B. Administer the digoxin as ordered
C. Put client on continuous cardiac monitoring
D. Reassess lung sounds in 30 minutes
A. Hold the digoxin and notify provider
(HR is 58 (bradycardia), potassium is low (3.2), and client reports yellow halos → all classic signs of digoxin toxicity. First action: hold medication and notify provider.)
A client with severe vomiting is admitted with Na⁺ 129, K⁺ 2.6, ABG shows metabolic alkalosis. The client is weak, has shallow respirations, and reports palpitations. Telemetry shows U waves.
Which intervention is the nurse’s priority?
A. Administer IV potassium as ordered
B. Start 0.45% NS
C. Provide oxygen at 2 L
D. Offer oral potassium supplements
A. Administer IV potassium as ordered
(K⁺ is 2.6 (very low) → client has weakness, palpitations, shallow respirations, and U waves on ECG. This is life-threatening hypokalemia, so IV potassium is the priority.)
A client newly prescribed lithium reports nausea, tremors, and diarrhea. Labs show lithium level 1.9 mEq/L and sodium 132.
What is the nurse’s priority?
A. Encourage fluid intake
B. Notify the provider of lithium toxicity
C. Give PRN antidiarrheals
D. Place the client on seizure precautions
Answer: B. Notify the provider of lithium toxicity
(Lithium level 1.9 mEq/L is toxic (therapeutic: 0.6–1.2). Symptoms: nausea, tremors, diarrhea, hyponatremia increases risk. First action: notify provider—toxicity can progress quickly.)
A client with suspected TB is coughing blood-tinged sputum and requires an urgent chest x-ray.
Which action is most appropriate by the nurse?
A. Transport with client wearing a surgical mask
B. Have the nurse wear an N95 and escort client uncovered
C. Delay test until negative sputum culture
D. Place client on contact precautions
Correct answer: A. Transport with client wearing a surgical mask
(TB = airborne, but patients wear a surgical mask during transport (not N95).)
A client receiving vancomycin develops flushing, pruritus, BP 88/50, and diffuse redness during infusion.
What is the nurse’s priority?
A. Slow the infusion rate
B. Stop the infusion and assess airway
C. Administer diphenhydramine
D. Check trough level
B. Stop the infusion and assess airway
(These findings = Red Man Syndrome)
A client with atrial fibrillation is receiving warfarin. The INR is 4.8. The client reports bleeding gums and dark stools.
Which intervention is the nurse’s priority?
A. Teach the client to avoid leafy greens
B. Prepare to administer vitamin K
C. Continue current dose and recheck INR in the morning
D. Encourage use of an electric razor
Answer: B. Prepare to administer vitamin K
(INR 4.8 (high) + bleeding gums + dark stools = bleeding risk. Priority is to reverse anticoagulation with vitamin K.)
A client with kidney failure has the following labs: K⁺ 6.8, Ca²⁺ 7.8, Mg²⁺ 2.8. The client reports tingling around the mouth and muscle twitching.
Which medication should the nurse prepare to administer first?
A. Insulin with dextrose
B. Kayexalate
C. IV calcium gluconate
D. Loop diuretic
C. IV calcium gluconate
(K⁺ is 6.8 → dangerous for heart, client has tingling & twitching. Calcium gluconate stabilizes the heart immediately. Other treatments (insulin/dextrose, Kayexalate) lower K⁺ later, but cardiac protection comes first.)
A client on haloperidol suddenly develops severe muscle rigidity, fever 103°F, hypertension, and altered mental status.
Which action should the nurse take first?
A. Administer IV fluids
B. Stop the haloperidol
C. Apply cooling blankets
D. Give acetaminophen
Answer: B. Stop the haloperidol
(Severe muscle rigidity, fever, altered mental status = a life-threatening reaction to antipsychotics. Stopping the medication immediately is priority.)
A client with C. diff has a Foley catheter, diarrhea 12× a day, and Stage 2 pressure injury.
Which nursing action is priority?
A. Obtain new stool sample
B. Implement strict contact precautions with handwashing
C. Apply moisture barrier cream
D. Increase oral fluids
answer: B. Implement strict contact precautions with handwashing
(C. diff = contact + soap & water (sanitizer doesn’t work).)
A client on gentamicin reports decreased urine output and ringing in the ears. Labs show BUN 38, creatinine 2.1.
What is the nurse’s priority action?
A. Encourage fluids
B. Notify provider of nephrotoxicity/ototoxicity
C. Continue medication and monitor
D. Hold fluids to prevent overload
answer: B. Notify provider of nephrotoxicity/ototoxicity
(Gentamicin = kidney + ear damage)
A client receiving nitroglycerin infusion for chest pain becomes hypotensive (BP 78/46). The client is pale, diaphoretic, and reports dizziness.
What is the nurse’s priority intervention?
A. Slow the nitroglycerin infusion
B. Stop the infusion and call the provider
C. Administer a fluid bolus per protocol
D. Reassess BP in 15 minutes
Answer: B. Stop the infusion and call the provider
(BP 78/46 + dizziness + pallor + diaphoresis = significant hypotension. First action: stop med to prevent shock.)
A postoperative client receiving large amounts of NG suction has Na⁺ 150 and shows irritability and restlessness.
What is the nurse’s priority intervention?
A. Start hypotonic solution
B. Encourage oral salt intake
C. Increase suction
D. Place client in high Fowler’s
Answer: A. Start hypotonic solution
(Na⁺ 150 → hypernatremia, client is restless & irritable. Hypotonic IV fluids (like 0.45% NS) will replenish water without adding more sodium.)
A client taking SSRIs and St. John’s wort reports sweating, tremors, agitation, and diarrhea.
Which intervention is the priority?
A. Hold the SSRI
B. Administer benzodiazepines
C. Teach about herbal interactions
D. Monitor temperature
Answer: A. Hold the SSRI
(Sweating, tremors, agitation, diarrhea → classic serotonin syndrome (SSRI + St. John’s wort))
A neutropenic client (WBC 900) has a visitor who arrives with a cough. The nurse should:
A. Allow visit if masked
B. Request the visitor return when asymptomatic
C. Place client in a negative pressure room
D. Encourage good handwashing
answer: B. Request the visitor return when asymptomatic
(Neutropenic = no immune system.
ANY sick visitor = no entry (even with mask) to prevent infection.)
A woman taking doxycycline for acne reports she just found out she is pregnant.
Which action is the nurse’s priority?
A. Encourage sun protection
B. Notify provider due to pregnancy risk
C. Teach to take with milk
D. Tell her it is safe to continue
answer: B. Notify provider due to pregnancy risk
(Tetracyclines = tooth discoloration + bone growth issues in fetus.)
A client receiving amiodarone for ventricular arrhythmias reports shortness of breath, productive cough, and new weight gain. Lung sounds reveal bilateral crackles.
Which action should the nurse anticipate?
A. Obtain a STAT chest x-ray
B. Increase amiodarone dose
C. Administer a bronchodilator
D. Encourage coughing and deep breathing
Answer: A. Obtain a STAT chest x-ray
(Shortness of breath, productive cough, weight gain, crackles → possible pulmonary toxicity or pulmonary edema from amiodarone. Imaging needed immediately.)
A client with hypomagnesemia (Mg²⁺ 1.0) is receiving magnesium sulfate IV. During infusion, the client’s respirations drop to 9/min, and deep tendon reflexes are absent.
What is the priority action?
A. Stop the infusion and administer calcium gluconate
B. Slow the infusion rate
C. Recheck magnesium level
D. Notify the provider only
A. Stop the infusion and administer calcium gluconate
(Mg²⁺ infusion → respirations 9/min + absent reflexes = magnesium toxicity. Calcium gluconate antagonizes magnesium and protects heart/muscles.)
A client taking clozapine reports sore throat and fever. Labs show WBC 2,000.
What is the nurse’s priority?
A. Hold medication and notify provider
B. Encourage fluids
C. Give antipyretics
D. Monitor temperature every hour
Answer: A. Hold medication and notify provider
(WBC 2,000 → agranulocytosis, which can be life-threatening. First step: stop the drug and notify provider; infection risk is high.)
A nurse contaminates a sterile field by accidentally brushing their sleeve over it. The nurse should:
A. Remove contaminated items only
B. Cover the contaminated area with a sterile drape
C. Replace entire sterile field
D. Continue if contamination was brief
answer: C. Replace entire sterile field
(Once contaminated = start over completely)
A client on ciprofloxacin for UTI develops severe calf pain and difficulty walking.
What should the nurse do first?
A. Apply warm compress
B. Hold the medication due to tendon rupture risk
C. Teach stretching exercises
D. Encourage ambulation
answer: B. Hold the medication due to tendon rupture risk
(fluoroquinolones will put you on the floor)
A client is prescribed ACE inhibitor therapy (lisinopril) for hypertension. After several doses, the client reports swelling of the lips and difficulty swallowing. Vitals: BP 140/82, HR 84, respirations 20, O₂ sat 94%.
What is the nurse’s priority?
A. Administer diphenhydramine
B. Elevate the head of the bed
C. Stop the medication and notify provider
D. Prepare for possible airway intervention
Answer: D. Prepare for possible airway intervention
(Swelling of lips + difficulty swallowing = angioedema, which can block airway. This is life-threatening.)
A client has calcium 6.7 mg/dL and is experiencing muscle spasms and a positive Chvostek sign. The client reports throat tightness.
Which action should the nurse take first?
A. Administer IV calcium
B. Prepare for possible intubation
C. Apply oxygen
D. Draw ABGs
Answer: B. Prepare for possible intubation
(Ca²⁺ 6.7 → muscle spasms, positive Chvostek sign, throat tightness = laryngeal spasm risk. Airway protection is priority. IV calcium is important, but first ensure airway safety.)
A client taking benzodiazepines for anxiety reports drinking 4–5 alcoholic beverages nightly. The nurse should prioritize which intervention?
A. Provide referral to AA
B. Assess for respiratory depression
C. Educate about alcohol avoidance
D. Notify the provider
B. Assess for respiratory depression
(Alcohol + benzos = CNS and respiratory depression risk. Priority: assess current respiratory status before education or referrals.)
A client with measles needs labs drawn. A new CNA prepares to enter wearing only gloves.
What should the nurse do first?
A. Instruct the CNA to add a gown
B. Stop the CNA and provide an N95 mask
C. Allow entry because gloves are enough
D. Ask the CNA to wash hands
answer: B. Stop the CNA and provide an N95 mask
(Measles = airborne, requires:
N95
gloves
gown
But the highest priority = respiratory protection first)
A client with pneumonia receiving high-dose IV penicillin suddenly develops wheezing, facial swelling, and difficulty breathing.
What is the nurse’s priority?
A. Stop the infusion and give epinephrine
B. Administer oxygen at 2 L
C. Give diphenhydramine
D. Notify provider
answer: A. Stop the infusion and give epinephrine
(anaphylaxis, so stop the med)