Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
A patient complains of shortness of breath when lying flat. What should the nurse ask next?
✔✔“Do you use pillows to sleep or have to sit up at night to breathe?”
While auscultating the lungs, the nurse hears crackles in the lower lobes. What should the nurse
assess next?
✔✔Signs of fluid overload or heart failure
A client reports a sudden headache that feels “like the worst ever.” What should the nurse do
immediately?
✔✔Initiate emergency evaluation for possible brain bleed
A patient complains of chest pain. What is the nurse’s immediate priority in assessment?
✔✔Assess location, severity, duration, and radiation of the pain
During assessment, the nurse notices unequal pupil size. What should the nurse do next?
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,✔✔Perform a full neurological exam
The nurse observes a diabetic patient with dry, cracked heels. What is a critical question to ask?
✔✔“Have you been inspecting your feet daily?”
A client’s blood pressure is 80/60 and the skin is cool and clammy. What should the nurse assess
next?
✔✔Level of consciousness and urine output
A patient is coughing up pink frothy sputum. What should the nurse suspect?
✔✔Pulmonary edema
During abdominal assessment, the nurse hears no bowel sounds for 5 minutes. What does this
likely indicate?
✔✔Possible bowel obstruction or paralytic ileus
A patient’s oxygen saturation drops to 88% on room air. What is the first assessment step?
✔✔Check airway patency and respiratory effort
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, A patient with liver disease has yellowing of the skin and eyes. What is this finding called?
✔✔Jaundice
The nurse palpates a thrill over the AV fistula of a dialysis patient. What should the nurse do
next?
✔✔Document the finding as normal
During inspection of the legs, one calf appears red, swollen, and warm. What should the nurse
do?
✔✔Suspect DVT and notify the provider
A client is restless, has rapid speech, and a flushed face. What is the nurse’s priority assessment?
✔✔Check temperature and mental status
The nurse is performing a neurological check. What finding requires immediate action?
✔✔Sudden drop in Glasgow Coma Scale
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