Rationale (2) Questions and Answers |
Latest Version | 2025/2026 | Correct &
Verified
A patient with diabetes reports dizziness and sweating. What is the priority action?
A. Wait for the next scheduled meal
✔✔B. Check blood glucose and administer rapid-acting carbohydrate
C. Encourage exercise
D. Document only
**Rationale:** Hypoglycemia is life-threatening and must be treated immediately.
A postoperative patient refuses to ambulate due to pain. What should the nurse do first?
A. Force ambulation
B. Wait until patient feels ready
✔✔C. Assess pain and provide analgesia before assisting
D. Ignore complaint
**Rationale:** Pain management is essential to safely facilitate ambulation and prevent
complications.
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,A patient is scheduled for surgery and asks why fasting is required. What is the best response?
A. To speed recovery
B. Because food interferes with anesthesia
✔✔C. To reduce the risk of aspiration during anesthesia
D. To make the stomach empty faster
**Rationale:** Fasting reduces the risk of aspiration while under anesthesia.
A patient develops sudden swelling of the lips and face after eating peanuts. What is the priority
nursing action?
A. Document and observe
B. Give oral antihistamine
✔✔C. Assess airway and prepare emergency intervention
D. Notify family
**Rationale:** Airway assessment is critical to prevent life-threatening anaphylaxis.
A child is admitted with fever and seizure activity. What is the priority nursing action?
A. Call provider after seizure
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,✔✔B. Ensure safety, maintain airway, and monitor seizure activity
C. Start IV fluids immediately
D. Document only
**Rationale:** Maintaining airway and safety is the first priority during seizures.
A patient is post-operative and has hypotension and tachycardia. What should the nurse do first?
A. Sit patient upright
B. Document only
✔✔C. Assess for bleeding and maintain IV access for fluid replacement
D. Call provider immediately
**Rationale:** Hypotension and tachycardia may indicate hemorrhage; rapid assessment and
intervention are critical.
A patient reports severe nausea after chemotherapy. What is the priority action?
A. Provide food
B. Document only
✔✔C. Assess severity and administer antiemetic as prescribed
D. Wait to see if it resolves
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, **Rationale:** Nausea can lead to dehydration and electrolyte imbalance; timely intervention is
necessary.
A patient with COPD reports increased shortness of breath and cyanosis. What should the nurse
do first?
A. Sit with patient
B. Wait for next vital signs
✔✔C. Administer prescribed oxygen and assess respiratory effort
D. Encourage coughing only
**Rationale:** Oxygen therapy and assessment of respiratory status are critical to prevent
hypoxia.
A patient develops a rash after IV antibiotic administration. What should the nurse do first?
A. Apply topical cream
B. Continue infusion
✔✔C. Stop infusion and notify provider
D. Document only
**Rationale:** Stopping the causative agent prevents further allergic reaction.
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