Fluids & Electrolytes
A client with severe diarrhea reports dizziness. Assessment findings include HR 118, BP 88/54, dry mucous membranes, and decreased skin turgor. What is the nurse’s priority action?
A. Place the client in high Fowler’s position
B. Administer IV isotonic fluids
C. Restrict oral fluids
D. Administer diuretics
B. Administer IV isotonic fluids
Priority: Restore circulating volume.
A client receives hepatitis B immune globulin after accidental exposure to blood. Which type of immunity does this provide?
A. Active natural immunity
B. Passive natural immunity
C. Active artificial immunity
D. Passive artificial immunity
D. Passive artificial immunity
The client receives preformed antibodies → passive + artificial.
Which assessment finding is most consistent with psoriasis?
A. Vesicular rash after poison ivy exposure
B. Thick, silvery plaques on extensor surfaces
C. Moist erythematous rash in skin folds
D. Urticarial wheals
B. Thick, silvery plaques on extensor surfaces
Classic psoriasis presentation.
A client with severe asthma suddenly has diminished wheezing and is silent on auscultation. What does this indicate?
A. Improvement
B. Airway obstruction worsening
C. Bronchospasm resolving
D. Pneumonia developing
B. Airway obstruction worsening
“Silent chest” = minimal airflow → impending respiratory failure.
A client reports chest pain that occurs at rest and is not relieved by nitroglycerin. This finding suggests:
A. Stable angina
B. Unstable angina
C. GERD
D. Musculoskeletal pain
B. Unstable angina
Unstable angina = rest pain + unrelieved by nitro.
A client with aplastic anemia has: Hgb 7.2, platelets 18,000 and ANC 350. Which complication is highest priority?
A. Fatigue
B. Bleeding
C. Infection
D. Dyspnea
C. Infection
ANC <500 = life-threatening infection risk.
A client receiving IV fluids develops crackles, dyspnea, and pink frothy sputum. Which intervention is priority?
A. Increase IV rate
B. Place client supine
C. Administer IV furosemide
D. Encourage oral fluids
C. Administer IV furosemide
Key finding: Pink frothy sputum = acute pulmonary edema.
After eating shellfish, a client develops wheezing, hypotension, and hives. What is the priority intervention?
A. Administer diphenhydramine IV
B. Administer epinephrine IM
C. Start oxygen via nasal cannula
D. Initiate IV fluids
B. Administer epinephrine IM
Epinephrine is first-line for airway compromise and hypotension.
A bedridden client with a Stage II heel injury is repositioned every 2 hours. Which additional intervention is most appropriate?
A. Massage the reddened area
B. Apply donut-shaped cushion
C. Elevate heels off the mattress
D. Apply heat packs
C. Elevate heels off the mattress
Heels should be completely floated.
Donuts and massage worsen tissue damage.
A client with suspected TB is admitted. Which room assignment is appropriate?
A. Private room with droplet precautions
B. Negative-pressure airborne isolation room
C. Standard precautions only
D. Cohort with pneumonia patients
B. Negative-pressure airborne isolation room
TB = airborne.
A client has BP 212/118 and reports severe headache and blurred vision. What is the priority concern?
A. Stroke
B. Dehydration
C. Hypotension
D. Arrhythmia
A. Stroke
End-organ damage = hypertensive emergency.
Which finding is most consistent with iron-deficiency anemia?
A. Elevated MCV
B. Glossitis and pica
C. Jaundice
D. Hypersegmented neutrophils
B. Glossitis and pica
Pica + glossitis are classic iron-deficiency findings.
A client receiving opioid pain medication has ABG results:
pH 7.30, PaCO₂ 55 mmHg, HCO₃⁻ 26 mEq/L. Which condition is present?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
B. Respiratory acidosis
Low pH + high CO₂ = respiratory acidosis (hypoventilation from opioids)
Which finding differentiates rheumatoid arthritis from osteoarthritis?
A. Joint pain improves with rest
B. Asymmetric joint involvement
C. Morning stiffness lasting over 1 hour
D. Heberden nodes
C. Morning stiffness lasting over 1 hour
RA = Autoimmune, prolonged morning stiffness.
A client has a sacral wound with full-thickness skin loss. Subcutaneous fat is visible, but bone, tendon, and muscle are not exposed. How should the nurse stage this injury?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
C. Stage III
Full-thickness + visible fat = Stage III.
Bone exposure = Stage IV.
A client with severe COPD is placed on 6 L/min nasal cannula. Two hours later the client is drowsy and difficult to arouse. What is the nurse’s priority action?
A. Increase oxygen flow
B. Obtain ABG
C. Discontinue oxygen
D. Encourage coughing
B. Obtain ABG
High O₂ can suppress respiratory drive in CO₂ retainers → check ABG.
A client with heart failure suddenly develops severe dyspnea, pink frothy sputum, and crackles. What is the nurse’s priority action?
A. Administer IV furosemide
B. Apply high-flow oxygen
C. Place client supine
D. Restrict fluids
B. Apply high-flow oxygen
Airway and oxygenation first.
A child with hemophilia falls and hits the knee. Swelling develops rapidly. What is the priority action?
A. Apply heat
B. Elevate and apply ice
C. Massage the joint
D. Encourage walking
B. Elevate and apply ice
RICE method (no heat, no massage).
A client with cerebral edema is prescribed 3% hypertonic saline. The nurse understands the purpose of this fluid is to:
A. Shift fluid into the intracellular space
B. Expand plasma volume rapidly
C. Pull fluid from the intracellular space into the vascular space
D. Replace free water losses
C. Pull fluid from the intracellular space into the vascular space
Hypertonic fluids pull water OUT of cells.
A client with HIV has a CD4 count of 180 cells/mm³. Which intervention is priority?
A. Encourage live vaccines
B. Initiate prophylaxis for opportunistic infections
C. Discontinue antiretroviral therapy
D. Restrict protein intake
B. Initiate prophylaxis for opportunistic infections
CD4 <200 → high risk for opportunistic infections (e.g., Pneumocystis jirovecii). Normal CD4: 500-1,500 cells/mm3
Which mole requires immediate follow-up?
A. Symmetrical with smooth border
B. Evenly pigmented brown lesion
C. 4 mm diameter mole
D. Irregular border with color variation
D. Irregular border with color variation
ABCDE rule → Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving.
After thoracentesis, a client becomes dyspneic with tracheal deviation. What is suspected?
A. Pulmonary embolism
B. Tension pneumothorax
C. Hemothorax
D. ARDS
B. Tension pneumothorax
Tracheal deviation = emergency.
A client with known abdominal aortic aneurysm reports sudden severe back pain and dizziness. What is the priority action?
A. Assess pedal pulses
B. Check blood pressure
C. Prepare for emergency surgery
D. Administer analgesics
C. Prepare for emergency surgery
Suspected rupture = life-threatening.
A client in vaso-occlusive crisis reports severe pain and O₂ saturation of 90%. What is the priority intervention?
A. Restrict fluids
B. Apply cold compresses
C. Administer oxygen
D. Encourage ambulation
C. Administer oxygen
Hypoxia worsens sickling.
A client with acute kidney injury has a potassium level of 6.4 mEq/L. The cardiac monitor shows peaked T waves. Which provider order should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate)
B. Initiate a 0.9% normal saline bolus
C. Administer IV calcium gluconate
D. Restrict dietary potassium
C. Administer IV calcium gluconate
Calcium gluconate stabilizes the myocardium immediately. This is priority before removing potassium from the body.
A client receiving chemotherapy has an ANC of 420. The client develops a temperature of 100.4°F (38°C). What is the nurse’s priority action?
A. Administer acetaminophen
B. Obtain blood cultures
C. Apply cooling blanket
D. Encourage oral fluids
B. Obtain blood cultures
In neutropenia, even a low-grade fever is a medical emergency. The priority is to identify infection source before antibiotics are started.
Fever in neutropenia = Sepsis until proven otherwise.
A client 5 days post–skin graft reports increased pain and the graft appears pale and cool. What does this indicate?
A. Normal healing
B. Infection
C. Graft rejection
D. Expected inflammation
C. Graft rejection
Pale, cool graft → poor perfusion → rejection risk.
A postoperative client suddenly develops sharp chest pain and dyspnea. O₂ sat 86%. What is the first action?
A. Administer heparin
B. Apply oxygen
C. Obtain D-dimer
D. Notify provider
B. Apply oxygen
ABCs first.
A client with chest pain has BP 78/40, HR 122, cool clammy skin, and crackles. What type of shock is most likely?
A. Septic
B. Hypovolemic
C. Cardiogenic
D. Anaphylactic
C. Cardiogenic
MI + hypotension + pulmonary congestion = cardiogenic shock.
A client on heparin has aPTT of 120 seconds. What is the nurse’s priority action?
A. Increase infusion rate
B. Stop infusion and notify provider
C. Administer vitamin K
D. Encourage green leafy vegetables
B. Stop infusion and notify provider
Therapeutic aPTT usually 1.5–2.5 times control.
120 seconds = excessive anticoagulation. Normal aPTT is 25-35 seconds.
A client has urine output of 800 mL/hr, serum sodium 152 mEq/L, and urine specific gravity 1.002. Which condition is most likely?
A. SIADH
B. Diabetes insipidus
C. Fluid volume overload
D. Acute renal failure
B. Diabetes insipidus
High sodium
Large urine output
Dilute urine
= Diabetes insipidus
Which assessment findings meet criteria for Systemic Inflammatory Response Syndrome (SIRS)? Select all that apply.
A. Temperature 101.9°F
B. Heart rate 112 bpm
C. Respiratory rate 24/min
D. WBC 3,200/mm³
E. Blood pressure 118/76
A. Temperature 101.9°F
B. Heart rate 112 bpm
C. Respiratory rate 24/min
D. WBC 3,200/mm³
SIRS criteria:
Temp >100.4 or <96.8
HR >90
RR >20
WBC >12,000 or <4,000
BP is not part of SIRS criteria.
Which finding most strongly suggests necrotizing fasciitis rather than cellulitis?
A. Redness and warmth
B. Low-grade fever
C. Severe pain out of proportion to exam
D. Localized swelling
C. Severe pain out of proportion to exam
Pain out of proportion = hallmark finding.
Which assessment finding in a client with pneumonia requires immediate intervention?
A. Crackles in right lower lobe
B. Temperature 101°F
C. Respiratory rate 34/min
D. Productive cough
C. Respiratory rate 34/min
RR >30 = respiratory distress.
A client with dilated cardiomyopathy reports increasing fatigue and dyspnea. Which finding requires immediate follow-up?
A. S3 heart sound
B. EF 30%
C. New onset atrial fibrillation
D. Bilateral ankle edema
C. New onset atrial fibrillation
A-fib increases risk of embolic stroke and hemodynamic instability.
A client receiving chemotherapy develops:potassium 6.0, uric acid elevated and creatinine rising. What complication is occurring?
A. Sepsis
B. DIC
C. Tumor lysis syndrome
D. Iron overload
C. Tumor lysis syndrome
Cell breakdown → hyperkalemia + kidney injury.
A client with prolonged vomiting has ABG results:
pH 7.50, PaCO₂ 48 mmHg, HCO₃⁻ 34 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Metabolic alkalosis with respiratory compensation
C. Respiratory alkalosis
D. Mixed alkalosis
B. Metabolic alkalosis with respiratory compensation
High pH = alkalosis
High HCO₃⁻ = metabolic cause
Elevated PaCO₂ = compensation
A client with a UTI becomes hypotensive (BP 84/48) despite receiving 30 mL/kg IV fluids. Lactate is elevated. Which intervention should the nurse anticipate next?
A. Begin vasopressor therapy
B. Administer corticosteroids
C. Start diuretics
D. Restrict fluids
A. Begin vasopressor therapy
Persistent hypotension after fluids = septic shock → vasopressors.
A client rescued from a house fire has singed nasal hairs, soot around the mouth, and hoarseness. What is the nurse’s priority action?
A. Apply cool compresses
B. Start IV fluids
C. Prepare for intubation
D. Assess burn depth
C. Prepare for intubation
Inhalation injury → airway edema can rapidly obstruct.
A chest tube becomes disconnected from the drainage system. What should the nurse do first?
A. Clamp the tube
B. Place tube end in sterile water
C. Apply petroleum gauze to insertion site
D. Notify provider
B. Place tube end in sterile water
Place in sterile water to create temporary water seal.
A client returns from a left femoral cardiac catheterization. One hour later the nurse notes: HR 118, BP 86/52, cool, pale skin, increasing restlessness and small amount of oozing at the insertion site. What is the nurse’s priority action?
A. Reinforce the dressing
B. Elevate the head of the bed
C. Apply firm pressure above the insertion site
D. Administer prescribed analgesics
C. Apply firm pressure above the insertion site
The insertion site looks minor, but:
Hypotension
Tachycardia
Restlessness
Pale, cool skin
= Active bleeding with hypovolemic shock
Pressure is applied 1–2 inches above the site (arterial access).
The nurse is caring for four clients. Which client should be assessed first?
A. A client with iron-deficiency anemia reporting fatigue
B. A client with thrombocytopenia and platelets 28,000 with petechiae
C. A client receiving heparin with aPTT 78 seconds
D. A client with sickle cell disease reporting sudden chest pain and shortness of breath
D. A client with sickle cell disease reporting sudden chest pain and shortness of breath
Sickle cell + chest pain + SOB = acute chest syndrome
This is a leading cause of death in sickle cell patients.
Respiratory compromise > bleeding risk > abnormal labs > fatigue.
A client with persistent vomiting has the following ABG results: pH 7.48, PaCO₂ 47 mmHg, HCO₃⁻ 33 mEq/L. How should the nurse interpret these findings?
A. Respiratory alkalosis
B. Metabolic alkalosis with respiratory compensation
C. Metabolic acidosis
D. Fully compensated respiratory acidosis
B. Metabolic alkalosis with respiratory compensation
pH 7.48 → Alkalosis
HCO₃⁻ 33 → Elevated → metabolic cause
PaCO₂ 47 → Elevated → lungs retaining CO₂ to compensate
Cause? Vomiting → loss of gastric acid → metabolic alkalosis.
A client is 3 months post–kidney transplant and taking tacrolimus and prednisone. During a clinic visit, the client asks about receiving vaccines. Which statement by the nurse is most appropriate?
A. “You should receive all routine live vaccines to strengthen immunity.”
B. “Live vaccines are contraindicated while you are taking immunosuppressants.”
C. “Vaccines are unnecessary because your immune system is suppressed.”
D. “You may receive any vaccine as long as you feel well.”
B. “Live vaccines are contraindicated while you are taking immunosuppressants.”
Transplant patients are on immunosuppressive therapy
Live vaccines (MMR, varicella, intranasal flu, zoster live) are contraindicated
Inactivated vaccines (flu shot, pneumococcal, Tdap) are generally safe
The nurse is caring for four clients in the burn unit. Which client should be assessed first?
A. A client 24 hours post-burn with urine output of 35 mL/hr
B. A client with 20% TBSA reporting pain level 9/10
C. A client with circumferential arm burns complaining of numbness and tingling
D. A client 3 days post-burn with temperature 100.4°F
C. A client with circumferential arm burns complaining of numbness and tingling
Circumferential burns can cause:
Compartment syndrome
Vascular compromise
Loss of distal circulation
Numbness and tingling = early neurovascular compromise → emergency.
A client on mechanical ventilation suddenly triggers a high-pressure alarm. The nurse notes the client is restless, oxygen saturation has dropped to 88%, and coarse crackles are heard bilaterally. What is the nurse’s priority action?
A. Increase the tidal volume
B. Assess the tubing for kinks
C. Suction the endotracheal tube
D. Administer a sedative
C. Suction the endotracheal tube
High-pressure alarm = resistance to airflow.
Common causes:
Secretions
Biting tube
Kinked tubing
Bronchospasm
The presence of coarse crackles + desaturation suggests mucus obstruction.
The nurse is assigned four clients. Which client should be assessed first?
A. A client with heart failure and bilateral crackles who gained 2 lb overnight
B. A client with atrial fibrillation and heart rate 118 bpm
C. A client with chest pain rated 6/10 relieved by nitroglycerin
D. A client 2 days post–MI who suddenly develops new confusion and BP 82/48
D. A client 2 days post–MI who suddenly develops new confusion and BP 82/48
New confusion + hypotension post-MI = possible:
Cardiogenic shock
Ventricular septal rupture
Papillary muscle rupture
Extension of infarct
This is unstable and life-threatening.
Two hours after receiving packed RBCs, a client develops: acute dyspnea, O₂ saturation 84%, crackles bilaterally, blood pressure 170/96 and jugular vein distention. What is the most likely complication?
A. Acute hemolytic reaction
B. Transfusion-related acute lung injury (TRALI)
C. Transfusion-associated circulatory overload (TACO)
D. Allergic reaction
C. Transfusion-associated circulatory overload (TACO)
The client has: Hypertension/JVD/Crackles/Hypoxia
That’s fluid overload, not immune lung injury.
TACO = cardiogenic pulmonary edema from too much volume.
TACO
Hypertension
JVD
Crackles
Fluid overload
Responds to diuretics
TRALI
Hypotension
No JVD
Non-cardiogenic pulmonary edema
Occurs within 6 hours
Hemolytic reaction
Fever
Chills
Back pain
Hypotension
Allergic reaction
Urticaria
Itching
No severe respiratory distress unless anaphylaxis