1. A patient with an ischemic stroke is receiving thrombolytic therapy.
Which finding requires immediate intervention?
A. Headache
B. Blood pressure of 180/100 mmHg
C. New-onset confusion
D. Blood glucose of 150 mg/dL
Answer and Rationale:
C. New-onset confusion
Rationale: This may indicate intracranial hemorrhage, a life-
threatening complication of thrombolytic therapy.
2. A patient recovering from a thoracotomy has a respiratory rate of 28
breaths/min and is using accessory muscles to breathe. What is the
nurse’s first action?
A. Increase oxygen delivery.
B. Assess pain level and provide analgesia.
C. Perform a respiratory assessment.
D. Notify the healthcare provider.
Answer and Rationale:
C. Perform a respiratory assessment.
,Rationale: Identifying the underlying cause of respiratory distress is
essential before intervening.
3. A patient is admitted with a potassium level of 6.5 mEq/L. Which
intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate).
B. Start an IV infusion of regular insulin and dextrose.
C. Monitor for peaked T waves on the ECG.
D. Administer calcium gluconate IV as prescribed.
Answer and Rationale:
D. Administer calcium gluconate IV as prescribed.
Rationale: Calcium gluconate stabilizes the cardiac membrane and
prevents arrhythmias, which is the priority in hyperkalemia
management.
4. A patient develops tachypnea, hypotension, and muffled heart
sounds. What is the nurse’s priority intervention?
A. Administer a fluid bolus.
B. Notify the healthcare provider immediately.
C. Prepare for pericardiocentesis.
D. Perform a focused cardiac assessment.
Answer and Rationale:
C. Prepare for pericardiocentesis.
, Rationale: These are signs of cardiac tamponade, requiring immediate
pericardiocentesis to relieve pressure.
5. A patient on digoxin presents with nausea, blurred vision, and a
heart rate of 48 bpm. What is the most appropriate nursing action?
A. Administer atropine.
B. Check digoxin levels.
C. Hold the next dose of digoxin.
D. Notify the healthcare provider.
Answer and Rationale:
B. Check digoxin levels.
Rationale: Symptoms suggest digoxin toxicity. Verifying serum levels
confirms the diagnosis and guides treatment.
6. The nurse is caring for a patient with a chest tube following thoracic
surgery. Which observation requires immediate action?
A. 50 mL of drainage in the last hour.
B. Continuous bubbling in the water seal chamber.
C. Tidaling in the water seal chamber during inspiration.
D. The chest tube is secured to the chest wall.
Answer and Rationale:
B. Continuous bubbling in the water seal chamber.
Which finding requires immediate intervention?
A. Headache
B. Blood pressure of 180/100 mmHg
C. New-onset confusion
D. Blood glucose of 150 mg/dL
Answer and Rationale:
C. New-onset confusion
Rationale: This may indicate intracranial hemorrhage, a life-
threatening complication of thrombolytic therapy.
2. A patient recovering from a thoracotomy has a respiratory rate of 28
breaths/min and is using accessory muscles to breathe. What is the
nurse’s first action?
A. Increase oxygen delivery.
B. Assess pain level and provide analgesia.
C. Perform a respiratory assessment.
D. Notify the healthcare provider.
Answer and Rationale:
C. Perform a respiratory assessment.
,Rationale: Identifying the underlying cause of respiratory distress is
essential before intervening.
3. A patient is admitted with a potassium level of 6.5 mEq/L. Which
intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate).
B. Start an IV infusion of regular insulin and dextrose.
C. Monitor for peaked T waves on the ECG.
D. Administer calcium gluconate IV as prescribed.
Answer and Rationale:
D. Administer calcium gluconate IV as prescribed.
Rationale: Calcium gluconate stabilizes the cardiac membrane and
prevents arrhythmias, which is the priority in hyperkalemia
management.
4. A patient develops tachypnea, hypotension, and muffled heart
sounds. What is the nurse’s priority intervention?
A. Administer a fluid bolus.
B. Notify the healthcare provider immediately.
C. Prepare for pericardiocentesis.
D. Perform a focused cardiac assessment.
Answer and Rationale:
C. Prepare for pericardiocentesis.
, Rationale: These are signs of cardiac tamponade, requiring immediate
pericardiocentesis to relieve pressure.
5. A patient on digoxin presents with nausea, blurred vision, and a
heart rate of 48 bpm. What is the most appropriate nursing action?
A. Administer atropine.
B. Check digoxin levels.
C. Hold the next dose of digoxin.
D. Notify the healthcare provider.
Answer and Rationale:
B. Check digoxin levels.
Rationale: Symptoms suggest digoxin toxicity. Verifying serum levels
confirms the diagnosis and guides treatment.
6. The nurse is caring for a patient with a chest tube following thoracic
surgery. Which observation requires immediate action?
A. 50 mL of drainage in the last hour.
B. Continuous bubbling in the water seal chamber.
C. Tidaling in the water seal chamber during inspiration.
D. The chest tube is secured to the chest wall.
Answer and Rationale:
B. Continuous bubbling in the water seal chamber.
