1. A patient is admitted with a suspected tension pneumothorax. What
is the nurse’s priority action?
A. Notify the healthcare provider immediately.
B. Prepare for needle decompression.
C. Administer supplemental oxygen.
D. Obtain a chest X-ray.
Answer and Rationale:
C. Administer supplemental oxygen.
Rationale: Oxygen supports tissue perfusion while definitive
interventions, such as needle decompression, are prepared.
2. A patient with a history of heart failure presents with sudden weight
gain of 5 lbs in 2 days, peripheral edema, and jugular vein distention.
What is the nurse’s priority intervention?
A. Administer prescribed diuretics.
B. Restrict oral fluid intake.
C. Monitor intake and output.
D. Elevate the legs to reduce edema.
Answer and Rationale:
A. Administer prescribed diuretics.
,Rationale: Diuretics help remove excess fluid and alleviate symptoms of
fluid overload.
3. A patient with end-stage renal disease reports severe itching. What
intervention is most appropriate?
A. Administer prescribed antihistamines.
B. Encourage increased water intake.
C. Monitor phosphorus levels.
D. Apply emollients to the skin.
Answer and Rationale:
C. Monitor phosphorus levels.
Rationale: Severe itching in renal patients is often due to
hyperphosphatemia. Addressing the cause is more effective than
symptom management alone.
4. A patient is receiving a continuous infusion of dopamine for
hypotension. Which finding indicates that the infusion rate may need to
be decreased?
A. Heart rate 110 bpm
B. Blood pressure 150/90 mmHg
C. Central venous pressure (CVP) 8 mmHg
D. Urine output 40 mL/hour
Answer and Rationale:
, B. Blood pressure 150/90 mmHg
Rationale: An elevated blood pressure suggests that the dopamine dose
is too high, potentially causing excessive vasoconstriction.
5. A patient with a history of aortic stenosis reports dizziness and chest
pain. The nurse observes a systolic murmur on auscultation. What is
the priority intervention?
A. Administer oxygen via nasal cannula.
B. Notify the healthcare provider immediately.
C. Place the patient in a supine position.
D. Obtain an electrocardiogram (ECG).
Answer and Rationale:
B. Notify the healthcare provider immediately.
Rationale: These symptoms suggest worsening aortic stenosis, a life-
threatening condition requiring prompt evaluation.
6. A patient receiving furosemide complains of muscle cramps. Which
lab value should the nurse assess?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Answer and Rationale:
is the nurse’s priority action?
A. Notify the healthcare provider immediately.
B. Prepare for needle decompression.
C. Administer supplemental oxygen.
D. Obtain a chest X-ray.
Answer and Rationale:
C. Administer supplemental oxygen.
Rationale: Oxygen supports tissue perfusion while definitive
interventions, such as needle decompression, are prepared.
2. A patient with a history of heart failure presents with sudden weight
gain of 5 lbs in 2 days, peripheral edema, and jugular vein distention.
What is the nurse’s priority intervention?
A. Administer prescribed diuretics.
B. Restrict oral fluid intake.
C. Monitor intake and output.
D. Elevate the legs to reduce edema.
Answer and Rationale:
A. Administer prescribed diuretics.
,Rationale: Diuretics help remove excess fluid and alleviate symptoms of
fluid overload.
3. A patient with end-stage renal disease reports severe itching. What
intervention is most appropriate?
A. Administer prescribed antihistamines.
B. Encourage increased water intake.
C. Monitor phosphorus levels.
D. Apply emollients to the skin.
Answer and Rationale:
C. Monitor phosphorus levels.
Rationale: Severe itching in renal patients is often due to
hyperphosphatemia. Addressing the cause is more effective than
symptom management alone.
4. A patient is receiving a continuous infusion of dopamine for
hypotension. Which finding indicates that the infusion rate may need to
be decreased?
A. Heart rate 110 bpm
B. Blood pressure 150/90 mmHg
C. Central venous pressure (CVP) 8 mmHg
D. Urine output 40 mL/hour
Answer and Rationale:
, B. Blood pressure 150/90 mmHg
Rationale: An elevated blood pressure suggests that the dopamine dose
is too high, potentially causing excessive vasoconstriction.
5. A patient with a history of aortic stenosis reports dizziness and chest
pain. The nurse observes a systolic murmur on auscultation. What is
the priority intervention?
A. Administer oxygen via nasal cannula.
B. Notify the healthcare provider immediately.
C. Place the patient in a supine position.
D. Obtain an electrocardiogram (ECG).
Answer and Rationale:
B. Notify the healthcare provider immediately.
Rationale: These symptoms suggest worsening aortic stenosis, a life-
threatening condition requiring prompt evaluation.
6. A patient receiving furosemide complains of muscle cramps. Which
lab value should the nurse assess?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Answer and Rationale:
