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Question 1
A nurse is caring for four clients. Which client should the nurse assess first?
A. Client with pneumonia and oxygen saturation of 89% on room air
B. Client with diabetes and blood glucose of 65 mg/dL who is alert
C. Client with a fractured tibia reporting pain of 7/10
D. Client with a urinary tract infection and temperature of 100.4°F (38°C)
Correct Answer: A
Rationale: Oxygen saturation <90% indicates hypoxemia, an airway/breathing
priority (ABCs). Hypoglycemia (65 mg/dL) is important but the client is alert. Pain
and mild fever are lower priority.
Question 2
A nurse is assessing a client with heart failure. Which finding requires immediate
action?
A. 2+ pitting edema
B. Crackles in lower lobes
C. Weight gain of 1 lb/day
D. Pink frothy sputum
Correct Answer: D
Rationale: Pink frothy sputum indicates acute pulmonary edema, a life-
threatening condition where fluid fills the alveoli, preventing gas exchange. This
requires immediate intervention such as oxygen, diuretics, and positioning.
Crackles indicate fluid but are not immediately life-threatening.
,Question 3
A charge nurse is making client assignments on a medical-surgical unit. Which
client should be assigned to the most experienced RN?
A. A client with stable diabetes mellitus requiring routine insulin administration
B. A client with pneumonia requiring q4h vital sign monitoring
C. A client with chest tubes and new-onset respiratory distress with SpO₂ of 88%
D. A client with a urinary tract infection requiring IV antibiotics
Correct Answer: C
Rationale: The client with chest tubes and new-onset respiratory distress is
unstable and requires complex assessment and immediate intervention—this
client should be assigned to the most experienced RN. Stable clients (A, B, D) can
be safely assigned to LPNs or less experienced RNs under appropriate supervision.
The ABC framework (Airway, Breathing, Circulation) prioritizes the client with
respiratory compromise.
Question 4
A nurse in an emergency department is performing triage for multiple clients
following a disaster. To which injury should the nurse assign the highest priority?
A. 95% full-thickness body burn
B. Below-knee amputation
C. Open tibia fracture
D. Simple laceration
Correct Answer: A
Rationale: In disaster triage, massive burns (>90% full-thickness) are often
classified as expectant (black tag) but require immediate evaluation. Among the
options, this client has the highest acuity and greatest need for immediate
intervention.
Question 5
A nurse is caring for four clients. Which client should be seen first?
A. Client with chest pain and diaphoresis
B. Client with a postoperative wound infection
,C. Client requesting pain medication
D. Client with a scheduled wound dressing change
Correct Answer: A
Rationale: Chest pain plus diaphoresis suggests acute myocardial infarction.
Airway, breathing, circulation (ABC) priorities indicate this client requires
immediate assessment and intervention.
Question 6
A nurse is assessing a client who is 1 day postoperative following abdominal
surgery. Which finding should the nurse report to the provider immediately?
A. Temperature of 99.2°F (37.3°C)
B. Heart rate of 88 beats/min
C. Respiratory rate of 22 breaths/min
D. Blood pressure of 88/52 mm Hg
Correct Answer: D
Rationale: A blood pressure of 88/52 mm Hg indicates hypotension, which can be
a sign of internal bleeding or hypovolemic shock. This is a circulation priority
(ABCs) and requires immediate provider notification. The other vital signs are
within normal limits.
Question 7
A nurse is preparing to administer a blood transfusion. Which action should the
nurse take first?
A. Obtain consent from the client
B. Verify the blood product with another licensed nurse
C. Check the client's vital signs
D. Start a saline lock
Correct Answer: B
Rationale: Verification of the blood product with another licensed nurse is the
most critical safety step to prevent transfusion reactions. Two nurses must verify
the client identification, blood type, Rh factor, and expiration date at the bedside.
, Question 8
A nurse is caring for a client who has a new tracheostomy. Which finding indicates
that the tracheostomy tube is obstructed?
A. Coughing up thick secretions
B. Respiratory rate of 18 breaths/min
C. Oxygen saturation of 96%
D. Diminished breath sounds on auscultation
Correct Answer: D
Rationale: Diminished or absent breath sounds indicate that air is not moving
through the tracheostomy tube, suggesting obstruction from a mucus plug or
other cause. This is an airway emergency requiring immediate intervention such
as suctioning.
Question 9
A nurse is providing care to a client who has a pneumothorax and a chest tube.
Which finding indicates that the chest tube drainage system is functioning
correctly?
A. Continuous bubbling in the water seal chamber
B. Intermittent bubbling in the water seal chamber
C. Absence of tidaling in the water seal chamber
D. Bloody drainage in the collection chamber
Correct Answer: B
Rationale: Intermittent bubbling in the water seal chamber is normal and
indicates air is being evacuated from the pleural space. Continuous bubbling
indicates an air leak. Absence of tidaling suggests obstruction or lung re-
expansion.
Question 10
A nurse is performing a focused respiratory assessment on a client. Which finding
requires immediate intervention?
A. Respiratory rate of 14 breaths/min
B. Use of accessory muscles to breathe