with 200 Realistic Questions and
Evidence-Based Rationales Covering
Fluid Balance, Wound Care, Delegation,
Medication Administration, and Critical
Thinking for Nursing Students
Section 1: Prioritization, Delegation, &
Management of Care
1. A client with a new tracheostomy is
restless and has a heart rate of 118
bpm. Which client should the nurse
assess first?
, • A. Client with pneumonia, O2
saturation 94% on room air.
• B. Client with a new tracheostomy,
pulse 118, restless.
• C. Client with diabetes, blood glucose
180 mg/dL.
• D. Client post-op day 2, complaining
of mild incisional pain.
☑VERIFIED ANSWER: B.
Rationale: Airway is always the first
priority (ABCs). The new tracheostomy
combined with tachycardia and
restlessness suggests potential hypoxia
or airway obstruction from a mucous
,plug or bleeding, requiring immediate
assessment.
2. The RN delegates vital signs to an
LPN. Which client should the RN NOT
delegate to the LPN?
• A. Client with stable hypertension.
• B. Client scheduled for discharge
teaching.
• C. Client returning from cardiac
catheterization with groin pressure.
• D. Client with chronic COPD on
maintenance oxygen.
☑VERIFIED ANSWER: C.
Rationale: An LPN cannot perform the
initial assessment of a client with a
, potential complication like bleeding or
hematoma formation post-cardiac
catheterization. The RN must assess this
client first.
3. A charge nurse is making
assignments. Which client is most
appropriate for a new graduate RN?
• A. Client on a continuous heparin drip
with PTT checks.
• B. Client 1-hour post-thyroidectomy
with neck swelling.
• C. Client with a nasogastric tube to
low intermittent suction.
• D. Client in restraints for pulling at
lines.