NIGHTINGALE BSN 366 EXAM 4 ACTUAL STYLE V3
(PDF) | 2026 EXAM QUESTIONS AND ANSWERS +
RATIONALES | STUDY GUIDE | 100% CORRECT
Section 1: Prioritization, Safety, and Medical-Surgical Nursing
1. A patient arrives at the emergency department with chest pain, diaphoresis, and nausea.
What is the nurse's first action?
A. Obtain a 12-lead ECG
B. Give an antacid for suspected indigestion
C. Offer the patient food
D. Document the patient's history
Answer: A. Obtain a 12-lead ECG
Rationale: Chest pain with diaphoresis and nausea are classic signs of an acute myocardial
infarction (MI). The priority is to obtain an ECG to identify ischemic changes and guide
immediate treatment. This is a life-threatening situation that requires rapid assessment .
2. A post-operative patient becomes tachycardic and hypotensive. The nurse suspects which
complication first?
A. Hemorrhage
B. Anxiety
C. Constipation
D. Fluid overload
Answer: A. Hemorrhage
Rationale: Tachycardia and hypotension in a post-operative patient are classic signs of
hypovolemic shock, most commonly caused by internal or external hemorrhage. This requires
immediate intervention to identify and stop the bleeding and restore circulating volume .
3. A patient with a history of asthma is having an exacerbation. Which medication should
the nurse administer first?
A. Albuterol
B. Insulin
C. Morphine
D. Furosemide (Lasix)
Answer: A. Albuterol
Rationale: Albuterol is a short-acting beta-agonist (SABA) bronchodilator that provides rapid
, relief of bronchospasm during an acute asthma attack. It is the first-line medication for acute
symptoms .
4. The nurse is providing discharge teaching to a client with COPD. Which statement
indicates a need for further education?
A. "I will stop smoking to slow the progression of my disease."
B. "I should eat more canned vegetables to reduce my sodium intake."
C. "I should use a salt substitute."
D. "I will eat more oatmeal for breakfast."
Answer: B. "I should eat more canned vegetables to reduce my sodium intake."
Rationale: Canned vegetables are often high in sodium, which can lead to fluid retention and
worsen symptoms in clients with COPD. Fresh or frozen vegetables are better choices. Smoking
cessation is the most important intervention, and a diet high in fiber (like oatmeal) and low in
sodium is encouraged .
5. A patient with a brain tumor has a tonic-clonic seizure that lasts 50 seconds. Following
the seizure, the patient is lethargic and confused. What should the nurse do?
A. Notify the emergency response team
B. Ask the wife to leave the room
C. Explain the postictal state to the family
D. Restrain the patient to prevent further injury
Answer: C. Explain the postictal state to the family
Rationale: The period following a seizure (postictal state) is characterized by confusion,
lethargy, and disorientation. This is a normal and expected phase. Reassuring the family and
providing education is the most appropriate nursing intervention .
Section 2: Maternal-Newborn Nursing
6. A client in active labor has a prolonged second stage. After the fetal head delivers, it
retracts tightly against the perineum (turtle sign). What is the priority nursing action?
A. Apply gentle suprapubic pressure
B. Apply fundal pressure
C. Call for assistance and prepare for shoulder dystocia maneuvers
D. Position the client in a hands-and-knees position
Answer: C. Call for assistance and prepare for shoulder dystocia maneuvers
Rationale: The "turtle sign" is a classic sign of shoulder dystocia. This is an obstetric emergency
(PDF) | 2026 EXAM QUESTIONS AND ANSWERS +
RATIONALES | STUDY GUIDE | 100% CORRECT
Section 1: Prioritization, Safety, and Medical-Surgical Nursing
1. A patient arrives at the emergency department with chest pain, diaphoresis, and nausea.
What is the nurse's first action?
A. Obtain a 12-lead ECG
B. Give an antacid for suspected indigestion
C. Offer the patient food
D. Document the patient's history
Answer: A. Obtain a 12-lead ECG
Rationale: Chest pain with diaphoresis and nausea are classic signs of an acute myocardial
infarction (MI). The priority is to obtain an ECG to identify ischemic changes and guide
immediate treatment. This is a life-threatening situation that requires rapid assessment .
2. A post-operative patient becomes tachycardic and hypotensive. The nurse suspects which
complication first?
A. Hemorrhage
B. Anxiety
C. Constipation
D. Fluid overload
Answer: A. Hemorrhage
Rationale: Tachycardia and hypotension in a post-operative patient are classic signs of
hypovolemic shock, most commonly caused by internal or external hemorrhage. This requires
immediate intervention to identify and stop the bleeding and restore circulating volume .
3. A patient with a history of asthma is having an exacerbation. Which medication should
the nurse administer first?
A. Albuterol
B. Insulin
C. Morphine
D. Furosemide (Lasix)
Answer: A. Albuterol
Rationale: Albuterol is a short-acting beta-agonist (SABA) bronchodilator that provides rapid
, relief of bronchospasm during an acute asthma attack. It is the first-line medication for acute
symptoms .
4. The nurse is providing discharge teaching to a client with COPD. Which statement
indicates a need for further education?
A. "I will stop smoking to slow the progression of my disease."
B. "I should eat more canned vegetables to reduce my sodium intake."
C. "I should use a salt substitute."
D. "I will eat more oatmeal for breakfast."
Answer: B. "I should eat more canned vegetables to reduce my sodium intake."
Rationale: Canned vegetables are often high in sodium, which can lead to fluid retention and
worsen symptoms in clients with COPD. Fresh or frozen vegetables are better choices. Smoking
cessation is the most important intervention, and a diet high in fiber (like oatmeal) and low in
sodium is encouraged .
5. A patient with a brain tumor has a tonic-clonic seizure that lasts 50 seconds. Following
the seizure, the patient is lethargic and confused. What should the nurse do?
A. Notify the emergency response team
B. Ask the wife to leave the room
C. Explain the postictal state to the family
D. Restrain the patient to prevent further injury
Answer: C. Explain the postictal state to the family
Rationale: The period following a seizure (postictal state) is characterized by confusion,
lethargy, and disorientation. This is a normal and expected phase. Reassuring the family and
providing education is the most appropriate nursing intervention .
Section 2: Maternal-Newborn Nursing
6. A client in active labor has a prolonged second stage. After the fetal head delivers, it
retracts tightly against the perineum (turtle sign). What is the priority nursing action?
A. Apply gentle suprapubic pressure
B. Apply fundal pressure
C. Call for assistance and prepare for shoulder dystocia maneuvers
D. Position the client in a hands-and-knees position
Answer: C. Call for assistance and prepare for shoulder dystocia maneuvers
Rationale: The "turtle sign" is a classic sign of shoulder dystocia. This is an obstetric emergency
