1
1. The nurse monitors a patient with congestive heart failure who reports increasing shortness of
breath while lying flat. Which action should the nurse take first?
A. Administer prescribed diuretic.
B. Raise the head of the bed to high-Fowler’s position.
C. Obtain a stat chest X-ray.
D. Restrict oral fluids.
Correct Answer: B
Rationale: Positioning promotes immediate lung expansion and reduces venous return,
providing rapid relief of orthopnea before medication effects begin.
2. A patient with COPD has a baseline oxygen saturation of 88%. The nurse notes the
saturation rises to 96% after increasing oxygen flow to 4 L/min. Which complication is the nurse
most concerned about?
A. Oxygen toxicity
, 2
B. Hypoventilation from loss of hypoxic drive
C. Pulmonary embolism
D. Respiratory alkalosis
Correct Answer: B
Rationale: Excess oxygen in COPD can suppress the hypoxic respiratory drive, causing CO₂
retention and hypoventilation. Maintain O₂ near baseline (88–92%).
3. The nurse caring for a post-op cholecystectomy patient notes shallow respirations and
reluctance to cough due to incisional pain. What is the priority nursing intervention?
A. Encourage deep breathing and splinting with a pillow.
B. Offer water to soothe the throat.
C. Increase IV fluids.
D. Apply cold packs to the incision.
Correct Answer: A
Rationale: Splinting reduces pain while promoting effective lung expansion, preventing
atelectasis and pneumonia.
4. A diabetic patient is diaphoretic, anxious, and shaky 2 hours after receiving insulin.
What is the nurse’s best action?
A. Check blood glucose and give 15 g of carbohydrates.
B. Administer scheduled insulin dose.
C. Call the provider for glucagon order.
D. Start an IV with D10W.
, 3
Correct Answer: A
Rationale: Symptoms indicate hypoglycemia. Confirm with glucose testing, then treat promptly
using the “15-15 rule” for mild cases.
5. A patient receiving furosemide for heart failure reports muscle weakness and cramping.
Which lab result should the nurse assess first?
A. Sodium level
B. Potassium level
C. Calcium level
D. Hemoglobin
Correct Answer: B
Rationale: Loop diuretics cause potassium loss leading to hypokalemia, which triggers muscle
weakness and dysrhythmias.
6. During an asthma exacerbation, which finding requires immediate intervention?
A. Wheezing on expiration
B. Absence of breath sounds
C. Cough with thick sputum
D. O₂ sat 90% on room air
Correct Answer: B
Rationale: A “silent chest” indicates severe airway obstruction or respiratory failure. Prepare for
emergency treatment and possible intubation.
, 4
7. A post-operative patient develops warm, red, tender calf swelling. What is the priority
nursing action?
A. Elevate the leg and notify the provider.
B. Apply sequential compression device.
C. Massage the calf gently.
D. Encourage ambulation.
Correct Answer: A
Rationale: Signs of deep vein thrombosis require limb elevation and immediate provider
notification; massage may dislodge a clot.
8. The nurse reviews ABG results: pH 7.30, PaCO₂ 50 mmHg, HCO₃⁻ 24 mEq/L. How
should these results be interpreted?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: C
Rationale: Low pH and elevated CO₂ indicate respiratory acidosis due to hypoventilation or
impaired gas exchange.
9. A patient with cirrhosis develops confusion and hand tremors. What medication does
the nurse anticipate administering?
A. Lactulose
1. The nurse monitors a patient with congestive heart failure who reports increasing shortness of
breath while lying flat. Which action should the nurse take first?
A. Administer prescribed diuretic.
B. Raise the head of the bed to high-Fowler’s position.
C. Obtain a stat chest X-ray.
D. Restrict oral fluids.
Correct Answer: B
Rationale: Positioning promotes immediate lung expansion and reduces venous return,
providing rapid relief of orthopnea before medication effects begin.
2. A patient with COPD has a baseline oxygen saturation of 88%. The nurse notes the
saturation rises to 96% after increasing oxygen flow to 4 L/min. Which complication is the nurse
most concerned about?
A. Oxygen toxicity
, 2
B. Hypoventilation from loss of hypoxic drive
C. Pulmonary embolism
D. Respiratory alkalosis
Correct Answer: B
Rationale: Excess oxygen in COPD can suppress the hypoxic respiratory drive, causing CO₂
retention and hypoventilation. Maintain O₂ near baseline (88–92%).
3. The nurse caring for a post-op cholecystectomy patient notes shallow respirations and
reluctance to cough due to incisional pain. What is the priority nursing intervention?
A. Encourage deep breathing and splinting with a pillow.
B. Offer water to soothe the throat.
C. Increase IV fluids.
D. Apply cold packs to the incision.
Correct Answer: A
Rationale: Splinting reduces pain while promoting effective lung expansion, preventing
atelectasis and pneumonia.
4. A diabetic patient is diaphoretic, anxious, and shaky 2 hours after receiving insulin.
What is the nurse’s best action?
A. Check blood glucose and give 15 g of carbohydrates.
B. Administer scheduled insulin dose.
C. Call the provider for glucagon order.
D. Start an IV with D10W.
, 3
Correct Answer: A
Rationale: Symptoms indicate hypoglycemia. Confirm with glucose testing, then treat promptly
using the “15-15 rule” for mild cases.
5. A patient receiving furosemide for heart failure reports muscle weakness and cramping.
Which lab result should the nurse assess first?
A. Sodium level
B. Potassium level
C. Calcium level
D. Hemoglobin
Correct Answer: B
Rationale: Loop diuretics cause potassium loss leading to hypokalemia, which triggers muscle
weakness and dysrhythmias.
6. During an asthma exacerbation, which finding requires immediate intervention?
A. Wheezing on expiration
B. Absence of breath sounds
C. Cough with thick sputum
D. O₂ sat 90% on room air
Correct Answer: B
Rationale: A “silent chest” indicates severe airway obstruction or respiratory failure. Prepare for
emergency treatment and possible intubation.
, 4
7. A post-operative patient develops warm, red, tender calf swelling. What is the priority
nursing action?
A. Elevate the leg and notify the provider.
B. Apply sequential compression device.
C. Massage the calf gently.
D. Encourage ambulation.
Correct Answer: A
Rationale: Signs of deep vein thrombosis require limb elevation and immediate provider
notification; massage may dislodge a clot.
8. The nurse reviews ABG results: pH 7.30, PaCO₂ 50 mmHg, HCO₃⁻ 24 mEq/L. How
should these results be interpreted?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: C
Rationale: Low pH and elevated CO₂ indicate respiratory acidosis due to hypoventilation or
impaired gas exchange.
9. A patient with cirrhosis develops confusion and hand tremors. What medication does
the nurse anticipate administering?
A. Lactulose
