Medications
Before administering furosemide (Lasix),this is the most important lab value to check.
Answer: What is the potassium level.
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. Checking potassium helps prevent dangerous arrhythmias.
These lab values (2) are critical for the nurse to monitor on patients receiving heparin therapy.
Answer: Platelet count and aPTT
Rationale: A falling platelet count may indicate heparin-induced thrombocytopenia (HIT), a life-threatening complication. aPTT measures clotting times and determines if the patient is at a therapeutic level.
Which patient should the nurse assess first?
A) Post-op day 1 knee replacement with pain 7/10
B) New onset chest pain, rating 6/10
C) Dressing change due at 9 AM
D) Discharge teaching for a patient going home today
Answer: B) New onset chest pain.
Rationale: Chest pain can signal myocardial infarction and is an immediate threat to life.
This is the single most effective way to prevent the spread of infection in the hospital.
Answer: What is hand hygiene.
Rationale: Handwashing or alcohol-based sanitizer use between patients is the #1 intervention to reduce healthcare-associated infections (HAIs).
Before inserting a peripheral IV, what is the first action the nurse should take?
Answer: Perform hand hygiene.
Rationale: Hand hygiene reduces infection risk and is the priority before any invasive procedure.
A patient is ordered metoprolol. This vital sign must be assessed before administration.
Answer: What is heart rate or pulse (hold if <60 bpm).
Rationale: Beta-blockers slow the heart rate; giving when bradycardic can cause heart block or symptomatic hypotension.
A patient’s calcium level is 7.0 mg/dL. What clinical sign should the nurse assess for?
Answer: Positive Chvostek’s or Trousseau’s sign.
Rationale: Hypocalcemia increases neuromuscular excitability, causing tetany and muscle spasms. Classic signs include facial twitching with facial nerve tap (Chvostek’s) or carpal spasm with BP cuff inflation (Trousseau’s).
Who is the highest priority?
A) Diabetic with blood glucose of 320 mg/dL
B) COPD patient with O₂ sat of 82% on 2L NC
C) UTI patient with temp 100.8°F
D) Hip fracture patient requesting pain meds
Answer: B) COPD patient with low O₂ sat.
Rationale: Airway and breathing are always highest priority in ABCs; hypoxemia can rapidly become fatal.
A confused patient keeps pulling at their IV and foley catheter. What is the safest first intervention?
Answer: Provide frequent observation, redirection, or a sitter.
Rationale: Least restrictive interventions are always attempted first; restraints are last resort.
At what angle should the nurse insert the needle for a subcutaneous injection?
Answer: 45–90 degrees, depending on the patient’s body type
Rationale: Thinner patients may require 45°, while average/heavier patients can tolerate 90° for correct tissue placement.
This is the safest way to identify a patient prior to administering a medication.
Answer: What is using two patient identifiers (name and DOB) and compare with the MAR and armband.
Rationale: This prevents medication errors by ensuring the right patient receives the correct drug, dose, and route.
A patient’s creatinine is 3.0 mg/dL. What does this indicate?
Answer: Severe renal impairment.
Rationale: Elevated creatinine indicates decreased kidney function and inability to excrete wastes, requiring medication adjustments.
The nurse is caring for four patients. Which one should be assessed first?
A) A patient with pneumonia, O₂ sat 90% on room air
B) A patient with a femur fracture requesting pain medication
C) A patient scheduled for discharge who needs teaching on insulin
D) A patient with heart failure who has gained 2 lbs since yesterday
Answer: A) Patient with pneumonia, O₂ sat 90% on room air.
Rationale: Using the ABCs, airway and breathing take priority. An O₂ sat of 90% indicates hypoxemia and requires immediate intervention before pain management, education, or fluid balance concerns.
The nurse is about to administer insulin but notices the dose seems higher than usual. What is the best action?
Answer: Verify the order with the provider before administering.
Rationale: If a medication dose seems unsafe, it must be clarified before administration to prevent harm. Nurses act as the last safety checkpoint.
When removing a wound dressing, what is the first step the nurse should take?
Answer: Don clean gloves.
Rationale: Clean gloves protect both nurse and patient before exposure to drainage or body fluids.
This is why you should never give IV potassium as a bolus/push.
Answer: What is causing fatal cardiac arrhythmias.
Rationale: IV potassium must always be diluted and infused slowly to prevent sudden hyperkalemia and cardiac arrest.
What does an elevated BNP (B-type natriuretic peptide) level indicate?
Answer: Heart failure exacerbation.
Rationale: BNP is released when the ventricles stretch due to fluid overload; it’s a key marker for CHF.
A patient with sepsis suddenly becomes confused and restless. What is the nurse’s priority action?
Answer: Assess oxygenation and provide supplemental O₂.
Rationale: Acute changes in mental status often indicate hypoxia; airway and oxygenation must be addressed before fluids, meds, or diagnostics.
A post-op patient is found on the floor after attempting to go to the bathroom alone. What is the priority nursing action?
Answer: Assess the patient for injuries.
Rationale: Patient safety comes first — assessment is always the initial step after a fall before notifying the provider or documenting.
A nurse is preparing to administer an IV piggyback antibiotic. What must be checked before connecting it to the primary line?
Answer: Medication and fluid compatibility.
Rationale: Incompatible medications/fluids can cause precipitation, inactivation, or patient harm.
A nurse is preparing medications and is interrupted multiple times. What are actions to prevent a med error?
Answer: Use a “do not disturb” or safety check protocol when preparing medications.
Rationale: Most med errors occur during interruptions. Creating a safety zone (quiet time, vests, signage) minimizes mistakes.
These ABG values indicate respiratory acidosis.
Answer: What is pH less than 7.35 and CO2 greater than 45?
Rationale: A low pH with elevated CO₂ indicates hypoventilation and CO₂ retention, as seen in COPD or respiratory depression.
Which post-op patient is at highest risk for complications?
A) Day 1 laparoscopic cholecystectomy, tolerating diet
B) Day 2 abdominal surgery with O₂ sat 89%
C) Day 3 hip replacement, ambulating with walker
D) Day 1 knee replacement, pain 6/10
Answer: B) Day 2 abdominal surgery with O₂ sat 89%.
Rationale: Low O₂ saturation after major abdominal surgery may indicate atelectasis, pneumonia, or pulmonary embolism, which can be life-threatening.
The nurse is caring for four patients. Which situation requires immediate intervention to maintain patient safety?
A) A patient receiving IV vancomycin with a mild red rash on the chest
B) A patient with a new central line requesting pain medication at the site
C) A patient on fall precautions found ambulating in the hall without nonslip socks
D) A patient prescribed hydromorphone reporting itching after the first dose
Answer: C) Patient on fall precautions found ambulating without nonslip socks.
Rationale: While the other issues need follow-up (possible Red Man Syndrome, central line pain, opioid side effect), the greatest immediate safety risk is the fall hazard, which can lead to severe injury. In prioritization, safety threats that are immediate and preventable (like falls) take precedence over less urgent side effects.
A patient with a tracheostomy has thick secretions and an SpO₂ of 84%. What is the priority nursing action?
Answer: Suction the tracheostomy.
Rationale: Airway always comes first (ABCs). Hypoxia due to secretion buildup requires immediate suctioning before oxygen adjustments or notifying the provider.