1. A client arrives with shortness of breath and SpO₂
of 88% on room air. Which action is priority?
o A. Obtain arterial blood gas (ABG)
o B. Apply supplemental oxygen
o C. Encourage deep breathing
o D. Notify provider
o Answer: B
o Rationale: Airway and oxygenation take
precedence (ABC) before diagnostics or
reporting.
2. A postoperative client has WBC 4,500/mm³. What
level of priority?
o A. Level A (low priority)
o B. Level B (moderate priority)
o C. Level C (high priority)
o D. No action needed
o Answer: C
o Rationale: WBC <5,000 indicates risk for
infection; high priority to assess and report
(Studocu).
,3. Which client first: A) chest pain 6/10, B) BP 88/50,
C) scheduled for ambulation after hip surgery, D)
blood glucose 300 mg/dL?
o Answer: B
o Rationale: Hypotension threatens perfusion (C in
ABC‐V) and requires immediate action.
4. A client with neutropenia (ANC 300) develops
fever 38.5°C. Priority action?
o A. Obtain blood cultures
o B. Administer antipyretics
o C. Start broad‐spectrum antibiotics
o D. Encourage fluids
o Answer: C
o Rationale: ANC <500 with fever indicates sepsis
risk; antibiotics within 1 hour.
5. Maslow’s highest priority for client with acute
pain and anxiety?
o A. Pain relief
o B. Emotional support
o C. Nutrition
o D. Sleep
o Answer: A
, o Rationale: Physiological needs (pain relief)
precede psychosocial.
6. A client on telemetry reports “fluttering” in chest;
next?
o A. Check telemetry strip
o B. Assess apical pulse
o C. Administer beta‐blocker
o D. Notify provider
o Answer: B
o Rationale: Assess patient (vs. monitor) first (first
step in nursing process).
7. Which lab to assess first in DKA: A) Na⁺, B) K⁺, C)
Glucose, D) BUN?
o Answer: B
o Rationale: Potassium shifts in DKA; risk of
arrhythmias.
8. A client post‐op hemorrhage (Hgb 6 g/dL) reports
weakness. Next?
o A. Encourage iron‐rich diet
o B. Prepare for transfusion
o C. Obtain Hct
o D. Monitor vital signs
o Answer: B
of 88% on room air. Which action is priority?
o A. Obtain arterial blood gas (ABG)
o B. Apply supplemental oxygen
o C. Encourage deep breathing
o D. Notify provider
o Answer: B
o Rationale: Airway and oxygenation take
precedence (ABC) before diagnostics or
reporting.
2. A postoperative client has WBC 4,500/mm³. What
level of priority?
o A. Level A (low priority)
o B. Level B (moderate priority)
o C. Level C (high priority)
o D. No action needed
o Answer: C
o Rationale: WBC <5,000 indicates risk for
infection; high priority to assess and report
(Studocu).
,3. Which client first: A) chest pain 6/10, B) BP 88/50,
C) scheduled for ambulation after hip surgery, D)
blood glucose 300 mg/dL?
o Answer: B
o Rationale: Hypotension threatens perfusion (C in
ABC‐V) and requires immediate action.
4. A client with neutropenia (ANC 300) develops
fever 38.5°C. Priority action?
o A. Obtain blood cultures
o B. Administer antipyretics
o C. Start broad‐spectrum antibiotics
o D. Encourage fluids
o Answer: C
o Rationale: ANC <500 with fever indicates sepsis
risk; antibiotics within 1 hour.
5. Maslow’s highest priority for client with acute
pain and anxiety?
o A. Pain relief
o B. Emotional support
o C. Nutrition
o D. Sleep
o Answer: A
, o Rationale: Physiological needs (pain relief)
precede psychosocial.
6. A client on telemetry reports “fluttering” in chest;
next?
o A. Check telemetry strip
o B. Assess apical pulse
o C. Administer beta‐blocker
o D. Notify provider
o Answer: B
o Rationale: Assess patient (vs. monitor) first (first
step in nursing process).
7. Which lab to assess first in DKA: A) Na⁺, B) K⁺, C)
Glucose, D) BUN?
o Answer: B
o Rationale: Potassium shifts in DKA; risk of
arrhythmias.
8. A client post‐op hemorrhage (Hgb 6 g/dL) reports
weakness. Next?
o A. Encourage iron‐rich diet
o B. Prepare for transfusion
o C. Obtain Hct
o D. Monitor vital signs
o Answer: B
