1. A patient presents with abdominal pain and a rigid abdomen. What
should the nurse do first?
A. Assess vital signs
B. Prepare the patient for surgery
C. Administer pain medication
D. Obtain a complete history
Answer: A. Assess vital signs
Rationale: A rigid abdomen may indicate peritonitis, which is life-
threatening. Vital signs help determine the patient’s stability.
2. A patient is receiving a potassium infusion for hypokalemia. Which
finding requires immediate nursing action?
A. Complaints of pain at the IV site
B. Potassium level of 3.8 mEq/L
C. U waves on the ECG
D. Irregular pulse
Answer: D. Irregular pulse
Rationale: An irregular pulse can indicate hyperkalemia or cardiac
instability, requiring immediate evaluation and intervention.
,3. A nurse is caring for a patient with a cervical spine injury. Which
action should the nurse prioritize?
A. Monitor for bowel and bladder function
B. Ensure the patient is in a neutral position
C. Assess the patient's pain level
D. Administer a tetanus shot as prescribed
Answer: B. Ensure the patient is in a neutral position
Rationale: Ensuring proper spinal alignment is crucial in preventing
further injury and neurological damage.
4. A patient with cirrhosis is at risk for hepatic encephalopathy. Which
assessment finding should the nurse report immediately?
A. Jaundice
B. Asterixis
C. Elevated liver enzymes
D. Generalized fatigue
Answer: B. Asterixis
Rationale: Asterixis (flapping tremor) indicates worsening hepatic
encephalopathy and requires immediate attention.
5. A nurse is preparing to administer an IV medication to a patient.
What is the nurse’s first action before administration?
A. Verify the patient’s allergies
, B. Assess the IV site for patency
C. Check the medication dose and label
D. Wash hands thoroughly
Answer: D. Wash hands thoroughly
Rationale: Hand hygiene is the first and most crucial step in preventing
infection when administering any medication.
6. A patient with diabetes is being discharged home with an insulin
regimen. Which statement by the patient indicates an understanding of
the teaching?
A. "I will take my insulin dose only when my blood sugar is high."
B. "I will store my insulin at room temperature for up to one month."
C. "I will rotate my injection sites to prevent tissue damage."
D. "I will stop taking insulin if I am feeling ill."
Answer: C. "I will rotate my injection sites to prevent tissue damage."
Rationale: Rotating injection sites prevents tissue damage and
promotes consistent absorption of insulin.
7. The nurse is teaching a patient with hypertension about lifestyle
modifications. Which statement by the patient indicates an
understanding of the teaching?
A. "I will increase my sodium intake to 4,500 mg daily."
B. "I will aim for at least 30 minutes of exercise most days."
should the nurse do first?
A. Assess vital signs
B. Prepare the patient for surgery
C. Administer pain medication
D. Obtain a complete history
Answer: A. Assess vital signs
Rationale: A rigid abdomen may indicate peritonitis, which is life-
threatening. Vital signs help determine the patient’s stability.
2. A patient is receiving a potassium infusion for hypokalemia. Which
finding requires immediate nursing action?
A. Complaints of pain at the IV site
B. Potassium level of 3.8 mEq/L
C. U waves on the ECG
D. Irregular pulse
Answer: D. Irregular pulse
Rationale: An irregular pulse can indicate hyperkalemia or cardiac
instability, requiring immediate evaluation and intervention.
,3. A nurse is caring for a patient with a cervical spine injury. Which
action should the nurse prioritize?
A. Monitor for bowel and bladder function
B. Ensure the patient is in a neutral position
C. Assess the patient's pain level
D. Administer a tetanus shot as prescribed
Answer: B. Ensure the patient is in a neutral position
Rationale: Ensuring proper spinal alignment is crucial in preventing
further injury and neurological damage.
4. A patient with cirrhosis is at risk for hepatic encephalopathy. Which
assessment finding should the nurse report immediately?
A. Jaundice
B. Asterixis
C. Elevated liver enzymes
D. Generalized fatigue
Answer: B. Asterixis
Rationale: Asterixis (flapping tremor) indicates worsening hepatic
encephalopathy and requires immediate attention.
5. A nurse is preparing to administer an IV medication to a patient.
What is the nurse’s first action before administration?
A. Verify the patient’s allergies
, B. Assess the IV site for patency
C. Check the medication dose and label
D. Wash hands thoroughly
Answer: D. Wash hands thoroughly
Rationale: Hand hygiene is the first and most crucial step in preventing
infection when administering any medication.
6. A patient with diabetes is being discharged home with an insulin
regimen. Which statement by the patient indicates an understanding of
the teaching?
A. "I will take my insulin dose only when my blood sugar is high."
B. "I will store my insulin at room temperature for up to one month."
C. "I will rotate my injection sites to prevent tissue damage."
D. "I will stop taking insulin if I am feeling ill."
Answer: C. "I will rotate my injection sites to prevent tissue damage."
Rationale: Rotating injection sites prevents tissue damage and
promotes consistent absorption of insulin.
7. The nurse is teaching a patient with hypertension about lifestyle
modifications. Which statement by the patient indicates an
understanding of the teaching?
A. "I will increase my sodium intake to 4,500 mg daily."
B. "I will aim for at least 30 minutes of exercise most days."
