Swift River 2 Questions and Answers
Latest Version 100% Pass
A patient is refusing to take their prescribed antihypertensive medication. What should the nurse
do first?
✔✔ Ask the patient why they are refusing and explore their concerns about the medication.
A client with COPD is receiving oxygen via nasal cannula at 5 L/min. What should the nurse do?
✔✔ Reduce the oxygen to 2 L/min and monitor for changes in mental status and respiratory
drive.
A post-op client has a heart rate of 120 bpm and is hypotensive. What is the nurse’s priority
action?
✔✔ Assess for signs of internal bleeding and notify the provider immediately.
A pediatric patient is crying and holding their ear. What should the nurse assess for?
✔✔ Possible ear infection; check temperature and inspect the ear for redness or drainage.
1
,A postpartum patient states, “I feel so overwhelmed and I can’t stop crying.” What is the best
nursing response?
✔✔ Validate her feelings and assess for signs of postpartum depression.
A diabetic patient has a blood glucose of 38 mg/dL and is unresponsive. What is the nurse’s first
action?
✔✔ Administer IV dextrose per protocol and monitor the airway.
A patient recovering from pneumonia complains of fatigue after walking to the bathroom. What
should the nurse do?
✔✔ Encourage frequent rest periods and monitor oxygen saturation during activity.
A patient with a new colostomy is embarrassed and refuses to look at the stoma. What should the
nurse do?
✔✔ Provide emotional support and involve the patient in stoma care at their comfort level.
A patient receiving chemotherapy reports a sore mouth and difficulty eating. What should the
nurse recommend?
✔✔ Encourage soft, bland foods and frequent mouth rinses with non-alcoholic solutions.
2
,A patient with schizophrenia says, “The voices are telling me to harm myself.” What is the
nurse’s priority action?
✔✔ Ensure patient safety and notify the mental health team immediately.
A patient with a urinary catheter reports abdominal pain and no urine output for 3 hours. What
should the nurse do?
✔✔ Check for catheter patency and irrigate if ordered.
A client with severe anxiety is hyperventilating and dizzy. What is the nurse’s best initial
intervention?
✔✔ Encourage slow, deep breathing using a paper bag or cupped hands.
A patient recovering from a hip replacement says they feel a “pop” in their hip while turning.
What should the nurse assess for?
✔✔ Possible dislocation; assess leg length, rotation, and pain.
A patient with dementia is frequently wandering at night. What is the safest intervention?
✔✔ Use bed and chair alarms and reorient the patient regularly.
3
, A post-op patient has not passed gas or had a bowel movement in three days. What should the
nurse do?
✔✔ Encourage ambulation and fluids, and assess bowel sounds.
A child is brought in with a barking cough and inspiratory stridor. What should the nurse prepare
for?
✔✔ Administer humidified oxygen and racemic epinephrine for suspected croup.
A patient says, “I’m allergic to penicillin,” and is ordered ampicillin. What should the nurse do?
✔✔ Hold the medication and notify the provider about the allergy.
A patient is complaining of calf pain and swelling after surgery. What is the nurse’s immediate
concern?
✔✔ Suspect deep vein thrombosis and avoid massaging the leg.
A patient reports severe chest pain after a central line placement. What is the nurse’s priority
action?
✔✔ Assess for signs of pneumothorax and notify the provider.
4
Latest Version 100% Pass
A patient is refusing to take their prescribed antihypertensive medication. What should the nurse
do first?
✔✔ Ask the patient why they are refusing and explore their concerns about the medication.
A client with COPD is receiving oxygen via nasal cannula at 5 L/min. What should the nurse do?
✔✔ Reduce the oxygen to 2 L/min and monitor for changes in mental status and respiratory
drive.
A post-op client has a heart rate of 120 bpm and is hypotensive. What is the nurse’s priority
action?
✔✔ Assess for signs of internal bleeding and notify the provider immediately.
A pediatric patient is crying and holding their ear. What should the nurse assess for?
✔✔ Possible ear infection; check temperature and inspect the ear for redness or drainage.
1
,A postpartum patient states, “I feel so overwhelmed and I can’t stop crying.” What is the best
nursing response?
✔✔ Validate her feelings and assess for signs of postpartum depression.
A diabetic patient has a blood glucose of 38 mg/dL and is unresponsive. What is the nurse’s first
action?
✔✔ Administer IV dextrose per protocol and monitor the airway.
A patient recovering from pneumonia complains of fatigue after walking to the bathroom. What
should the nurse do?
✔✔ Encourage frequent rest periods and monitor oxygen saturation during activity.
A patient with a new colostomy is embarrassed and refuses to look at the stoma. What should the
nurse do?
✔✔ Provide emotional support and involve the patient in stoma care at their comfort level.
A patient receiving chemotherapy reports a sore mouth and difficulty eating. What should the
nurse recommend?
✔✔ Encourage soft, bland foods and frequent mouth rinses with non-alcoholic solutions.
2
,A patient with schizophrenia says, “The voices are telling me to harm myself.” What is the
nurse’s priority action?
✔✔ Ensure patient safety and notify the mental health team immediately.
A patient with a urinary catheter reports abdominal pain and no urine output for 3 hours. What
should the nurse do?
✔✔ Check for catheter patency and irrigate if ordered.
A client with severe anxiety is hyperventilating and dizzy. What is the nurse’s best initial
intervention?
✔✔ Encourage slow, deep breathing using a paper bag or cupped hands.
A patient recovering from a hip replacement says they feel a “pop” in their hip while turning.
What should the nurse assess for?
✔✔ Possible dislocation; assess leg length, rotation, and pain.
A patient with dementia is frequently wandering at night. What is the safest intervention?
✔✔ Use bed and chair alarms and reorient the patient regularly.
3
, A post-op patient has not passed gas or had a bowel movement in three days. What should the
nurse do?
✔✔ Encourage ambulation and fluids, and assess bowel sounds.
A child is brought in with a barking cough and inspiratory stridor. What should the nurse prepare
for?
✔✔ Administer humidified oxygen and racemic epinephrine for suspected croup.
A patient says, “I’m allergic to penicillin,” and is ordered ampicillin. What should the nurse do?
✔✔ Hold the medication and notify the provider about the allergy.
A patient is complaining of calf pain and swelling after surgery. What is the nurse’s immediate
concern?
✔✔ Suspect deep vein thrombosis and avoid massaging the leg.
A patient reports severe chest pain after a central line placement. What is the nurse’s priority
action?
✔✔ Assess for signs of pneumothorax and notify the provider.
4
