Critical Thinking Nursing Exam – Priority Interventions & Discharge Planning Comprehensive Practice Examination

Critical Thinking Nursing Exam – Priority
Interventions & Discharge Planning
Comprehensive Practice Examination
Section 1: Priority Interventions (Questions 1-20)
1. A nurse is caring for a patient who is experiencing chest pain. Which action should be taken
first?
 A) Administer morphine
 B) Obtain a 12-lead ECG
 C) Administer aspirin
 D) Assess the patient's pain level
Answer: B) Obtain a 12-lead ECG
Rationale: ECG is the priority to identify the cause of chest pain. Aspirin (C) and morphine (A) are
important but after ECG. Pain assessment (D) is ongoing.


2. A patient is experiencing respiratory distress. What is the priority nursing intervention?
 A) Administer oxygen
 B) Position the patient upright
 C) Assess the respiratory rate
 D) Call the provider
Answer: A) Administer oxygen
Rationale: Oxygen is the priority for respiratory distress. Positioning upright (B) is also important
but oxygen is first. Assessment (C) and calling provider (D) come after.


3. A patient has fallen and is not moving. What is the priority action?
 A) Assess for injury
 B) Call for help
 C) Assess the patient's airway

,  D) Check for paralysis
Answer: C) Assess the patient's airway
Rationale: Airway is the priority in the ABCs. Assess for injury (A), call for help (B), and check for
paralysis (D) are important but after airway assessment.


4. A patient is experiencing anaphylaxis. Which medication should be administered first?
 A) Epinephrine
 B) Antihistamine
 C) Corticosteroid
 D) Bronchodilator
Answer: A) Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis. Antihistamines (B),
corticosteroids (C), and bronchodilators (D) are adjunctive.


5. A patient is experiencing chest pain and has a history of angina. Which symptom would
indicate a myocardial infarction rather than angina?
 A) Pain with exertion
 B) Pain relieved by rest
 C) Pain not relieved by nitroglycerin
 D) Pain in the chest
Answer: C) Pain not relieved by nitroglycerin
Rationale: Unrelieved pain suggests MI. Pain with exertion (A) and relief with rest (B) are
angina, and chest pain (D) is nonspecific.


6. A patient is experiencing a seizure. What is the priority nursing intervention?
 A) Restrain the patient
 B) Insert a bite block
 C) Position the patient on their side
 D) Call the provider

,Answer: C) Position the patient on their side
Rationale: Positioning on the side prevents aspiration. Restraining (A) is not recommended, bite
blocks (B) are not recommended, and calling the provider (D) comes after.


7. A patient is experiencing hypotension and tachycardia. Which intervention should be
prioritized?
 A) Administer IV fluids
 B) Administer vasopressors
 C) Monitor vital signs
 D) Call the provider
Answer: A) Administer IV fluids
Rationale: IV fluids are first-line for hypotension. Vasopressors (B) are second-line, monitoring
(C) is ongoing, and calling provider (D) is needed but fluids are the priority.


8. A patient has a medication error. What is the priority nursing action?
 A) Document the error
 B) Assess the patient
 C) Notify the provider
 D) Complete an incident report
Answer: B) Assess the patient
Rationale: The patient's safety is the priority. Documentation (A), notification (C), and incident
report (D) are important but after assessment.


9. A patient is experiencing acute kidney injury. Which intervention is most important?
 A) Monitor fluid balance
 B) Administer diuretics
 C) Monitor electrolytes
 D) Restrict fluid

, Answer: A) Monitor fluid balance
Rationale: Fluid balance is essential for AKI. Diuretics (B) may be given, electrolytes (C) should be
monitored, and fluid restriction (D) may be needed but monitoring is first.


10. A patient is experiencing delirium. What is the priority nursing intervention?
 A) Reorient the patient
 B) Provide a calm environment
 C) Assess for underlying causes
 D) Administer antipsychotics
Answer: C) Assess for underlying causes
Rationale: Identifying the cause is the priority for delirium. Reorientation (A), calm environment
(B), and antipsychotics (D) are important but assessment is first.


11. A patient is experiencing severe pain. Which intervention should be prioritized?
 A) Assess the pain level
 B) Administer pain medication
 C) Apply heat or cold
 D) Reassure the patient
Answer: A) Assess the pain level
Rationale: Assessment precedes intervention. Administering medication (B), applying heat/cold
(C), and reassurance (D) come after assessment.


12. A patient is experiencing a stroke. Which intervention is most time-sensitive?
 A) Administer tPA
 B) Administer aspirin
 C) Assess neurological status
 D) Obtain a CT scan
Answer: A) Administer tPA
Rationale: tPA is time-sensitive within 4.5 hours. Aspirin (B) is used for ischemic stroke,
neurological assessment (C) is ongoing, and CT scan (D) is needed first but tPA is the treatment.