Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
A client with a leg cast reports tingling and numbness in the toes. What is the nurse’s priority
action?
✔✔ A. Assess neurovascular status of the affected limb
B. Administer pain medication
C. Reposition the leg on a pillow
D. Offer emotional support
A nurse is caring for four clients. Which one should be assessed first?
A. A client with a temperature of 100.8°F
✔✔ B. A client with a new onset of confusion and restlessness
C. A client requesting assistance with feeding
D. A client who is sleeping soundly
Which of the following actions demonstrates the “least invasive” framework?
✔✔ A. Encouraging coughing and deep breathing before suctioning
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,B. Performing nasopharyngeal suctioning immediately
C. Inserting a nasogastric tube
D. Applying a chest tube
A client reports chest pressure and shortness of breath. What should the nurse do first?
✔✔ A. Assess vital signs and oxygen saturation
B. Notify the provider
C. Administer nitroglycerin
D. Reassure the client
A client has new slurred speech and unilateral facial drooping. What is the priority action?
A. Perform a full neurologic assessment
✔✔ B. Activate the stroke response team
C. Offer water and assess swallowing
D. Document the findings
The nurse is assigning care. Which client should be seen first?
✔✔ A. A client with sudden onset of wheezing
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, B. A client due for discharge education
C. A client who needs assistance ordering dinner
D. A client who needs daily dressing change
Which of the following best demonstrates the “actual vs. potential” framework?
A. Teaching a client about fall prevention
✔✔ B. Responding to a client who just fell out of bed
C. Discussing safety measures with family
D. Ensuring the call light is within reach
Which client condition requires **immediate attention** based on the ABC framework?
A. A client with a chronic cough
✔✔ B. A client with audible wheezing and cyanosis
C. A client who is sleepy but arousable
D. A client who is vomiting
A nurse finds a client with a tracheostomy having difficulty breathing. What is the first action?
✔✔ A. Check the tracheostomy tube for patency
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