Cardiovascular
A client with chest pain has nitroglycerin ordered. BP is 88/54. What is the nurse's priority action?
Hold the nitroglycerin and notify the provider.
A COPD patient is receiving oxygen at 6 L/min via nasal cannula and becomes drowsy. What is the nurse's priority concern?
Oxygen-induced hypoventilation / Co2 retention.
A diabetic patient is sweaty, shaky, and confused. Blood glucose is 48. What is the priority action?
Give fast-acting glucose (hypoglycemia treatment)
A client has urine output of 15 mL/hr for 3 hours post-op. What is the nurse's priority action?
Assess for hypovolemia and notify provider.
A stroke patient suddenly develops unequal pupils and decreasing LOC. What is the priority concern?
A client with heart failure has crackles, weight gain of 3 lbs in 2 days, and edema. What does this most likely indicate?
Fluid volume overload/ exacerbation of heart failure.
A client has sudden shortness of breath, chest pain, and hemoptysis. What complication does the nurse suspect first?
Pulmonary embolism.
A patient with DKA has Kussmaul respirations. What does this indicate?
Metabolic acidosis compensation.
A patient with CKD has elevated potassium. What ECG change is most concerning?
Peaked T waves.
A patient post-seizure is confused and drowsy. What phase is this?
Postictal phase
The nurse sees ST elevation on the ECG. What is the priority interpretation?
Acute myocardial infarction.
A patient with pneumonia has a rising RR and decreasing LOC. What is the priority action?
Suspect respiratory failure and escalate care immediately.
Why is potassium closely monitored when starting insulin in DKA?
Insulin shifts potassium into cells > risk of hypokalemia.
A client receiving dialysis becomes hypotensive. What is the priority action?
Stop or slow dialysis and place patient supine.
A client with head injury has clear fluid leaking from nose. What should the nurse suspect?
CSF leak (skull fracture)
A client on digoxin has nausea, blurred vision, and a heart rate of 48. What is the priority action?
Hold digoxin and notify provider. (Possible toxicity)
Which oxygen delivery system requires the most precise oxygen concentration delivery?
Venturi mask.
A patient post-thyroidectomy develops stridor and tingling around mouth. What is the priority action?
Suspect hypocalcemia > prepare calcium gluconate
Why is fluid restriction important in end-stage renal disease?
Kidneys cannot excrete excess fluid > risk of overload.
A patient with suspected stroke arrives. What is the nurse's first action?
Establish time last known well (priority for thrombolytics)
A client in atrial fibrillation is started on heparin. What lab must be monitored?
aPTT or anti-Xa
A patient is using accessory muscles and has silent chest sounds during an asthma attack. What does this indicate?
Severe airway obstruction (life-threatening asthma)
A client with Addison's disease is at highest risk for what life-threatening condition?
Addisonian crisis.
A client has cloudy, foul-smelling urine and fever. What is the priority concern?
Urinary tract infection (Possible pyelonephritis/sepsis risk)
Why is mannitol given in increased ICP?
It draws fluid out of brain tissue to reduce swelling.