1. A client with pneumonia has an oxygen saturation of 88% on room air. What is the
priority action?
A. Increase fluid intake
B. Apply supplemental oxygen
C. Encourage coughing exercises
D. Call respiratory therapy
Answer: B
Rationale: Low O2 sat requires immediate oxygen support.
2. Which client should the nurse assess first?
A. COPD patient with productive cough
B. Post-op client with pain 8/10
C. New onset confusion in an elderly patient
D. Diabetic patient asking for dinner tray
Answer: C
Rationale: Sudden confusion may indicate hypoxia or stroke.
3. Digoxin level is 2.8 ng/mL. What action is priority?
A. Give scheduled dose
B. Hold dose and notify provider
C. Increase potassium
D. Document and recheck in the morning
Answer: B
Rationale: Normal digoxin 0.5–2.0; >2 indicates toxicity.
4. A patient receiving furosemide is at risk for which electrolyte imbalance?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hyponatremia
Answer: C
5. The charge nurse is making assignments. Which client is suitable for LPN care?
A. Unstable acute stroke
B. Fresh post-op requiring assessment
C. Stable client with chronic wound care
, D. Patient on titrated IV nitro
Answer: C
6. A nurse enters a room and finds the client on the floor. What is the first action?
A. Notify provider
B. Fill incident report
C. Assess for injury
D. Call rapid response
Answer: C
7. A patient is prescribed warfarin. Which lab must be monitored?
A. PTT
B. Hemoglobin
C. Platelets
D. INR
Answer: D
8. New order: Heparin infusion. Which antidote must be available?
Protamine sulfate
9. A patient with TB must be placed in which precautions?
A. Contact
B. Droplet
C. Airborne
D. Neutropenic
Answer: C
10. Which action prevents catheter-associated UTIs?
A. Apply povidone daily
B. Keep drainage bag below bladder
C. Change catheter daily
D. Irrigate each shift
Answer: B
PRIORITY / TRIAGE (11–25)