Nightingale College BSN 366 Exam 2 (pdf) | 2026/2027 | Concepts of
Nursing IV Q&A | Nursing
1. A nurse receives four clients at the start of the shift. Which client should
the nurse assess first?
A) Client requesting pain medication for chronic back pain
B) Client with asthma reporting mild wheezing
C) Client with chest pain rated 8/10 and diaphoresis
D) Client scheduled for discharge teaching
Correct Answer: Client with chest pain rated 8/10 and diaphoresis
Rationale: Chest pain with diaphoresis suggests a possible acute coronary
syndrome, which is a life-threatening emergency requiring immediate
intervention. The other clients have stable conditions or routine needs that
can be addressed after the client with the emergent condition is stabilized.
2. What is the highest priority action for a nurse immediately after a patient
falls?
A) Document the incident in the patient's chart
B) Notify the patient's family members
C) Assess the patient for injuries
D) Complete an incident report
Correct Answer: Assess the patient for injuries
Rationale: Assessment for injury is the priority to identify life-threatening
issues such as fractures or head trauma before any documentation or
notification. The safety and well-being of the patient always come first.
,3. Which patient finding requires the most immediate nursing intervention?
A) Blood pressure 140/90 mmHg
B) Respiratory rate of 28 breaths per minute with anxiety
C) Urine output of 30 mL/hr
D) Temperature of 37.8°C (100°F)
Correct Answer: Respiratory rate of 28 breaths per minute with anxiety
Rationale: An increased respiratory rate with anxiety may indicate
respiratory distress or an impending respiratory failure, which requires
immediate assessment and intervention. The other findings are abnormal but
less immediately life-threatening.
4. Which action should the nurse take first when a patient is suspected of
having a transfusion reaction?
A) Notify the healthcare provider
B) Stop the transfusion immediately
C) Take the patient's vital signs
D) Administer an antihistamine
Correct Answer: Stop the transfusion immediately
Rationale: Stopping the transfusion prevents further exposure to the antigen
causing the reaction. This is the priority action to prevent the progression of
a potentially fatal hemolytic reaction.
5. A post-operative patient is restless and confused. What is the nurse's
priority action?
A) Apply soft wrist restraints
,B) Assess the patient's oxygen saturation
C) Administer a PRN sedative
D) Call the patient's family
Correct Answer: Assess the patient's oxygen saturation
Rationale: Hypoxia is a common cause of acute confusion in post-operative
patients. Assessing oxygen saturation is the priority to rule out this life-
threatening cause before considering other interventions.
6. Which laboratory value is most concerning and requires immediate action?
A) Serum sodium of 138 mEq/L
B) Serum potassium of 6.2 mEq/L
C) Hemoglobin of 13 g/dL
D) Serum calcium of 9.2 mg/dL
Correct Answer: Serum potassium of 6.2 mEq/L
Rationale: A serum potassium of 6.2 mEq/L indicates severe hyperkalemia,
which can cause lethal cardiac dysrhythmias. This requires immediate
intervention, such as administering calcium gluconate, insulin with glucose,
or sodium polystyrene sulfonate.
7. A client reports a sudden, severe headache and vomiting. What is the
priority nursing action?
A) Administer acetaminophen for the headache
B) Assess the client's neurological status
C) Prepare the client for a CT scan
D) Lower the room lighting
, Correct Answer: Assess the client's neurological status
Rationale: A sudden, severe headache with vomiting may indicate increased
intracranial pressure or a hemorrhage. A neurological assessment is the
priority to identify any changes in level of consciousness, pupillary response,
or motor function.
8. Which patient is at the greatest risk for developing an infection?
A) A patient with diabetes and a foot ulcer
B) A patient with hypertension
C) A patient with asthma
D) A patient with a migraine
Correct Answer: A patient with diabetes and a foot ulcer
Rationale: Diabetes impairs the immune system and circulation, and a foot
ulcer provides a direct portal of entry for pathogens. This patient is at the
highest risk for infection among the options.
9. What is the priority action for a nurse during an acute exacerbation of
COPD?
A) Administer high-flow oxygen via non-rebreather mask
B) Administer low-flow oxygen via nasal cannula
C) Administer a nebulizer treatment PRN only
D) Restrict fluid intake
Correct Answer: Administer low-flow oxygen via nasal cannula
Nursing IV Q&A | Nursing
1. A nurse receives four clients at the start of the shift. Which client should
the nurse assess first?
A) Client requesting pain medication for chronic back pain
B) Client with asthma reporting mild wheezing
C) Client with chest pain rated 8/10 and diaphoresis
D) Client scheduled for discharge teaching
Correct Answer: Client with chest pain rated 8/10 and diaphoresis
Rationale: Chest pain with diaphoresis suggests a possible acute coronary
syndrome, which is a life-threatening emergency requiring immediate
intervention. The other clients have stable conditions or routine needs that
can be addressed after the client with the emergent condition is stabilized.
2. What is the highest priority action for a nurse immediately after a patient
falls?
A) Document the incident in the patient's chart
B) Notify the patient's family members
C) Assess the patient for injuries
D) Complete an incident report
Correct Answer: Assess the patient for injuries
Rationale: Assessment for injury is the priority to identify life-threatening
issues such as fractures or head trauma before any documentation or
notification. The safety and well-being of the patient always come first.
,3. Which patient finding requires the most immediate nursing intervention?
A) Blood pressure 140/90 mmHg
B) Respiratory rate of 28 breaths per minute with anxiety
C) Urine output of 30 mL/hr
D) Temperature of 37.8°C (100°F)
Correct Answer: Respiratory rate of 28 breaths per minute with anxiety
Rationale: An increased respiratory rate with anxiety may indicate
respiratory distress or an impending respiratory failure, which requires
immediate assessment and intervention. The other findings are abnormal but
less immediately life-threatening.
4. Which action should the nurse take first when a patient is suspected of
having a transfusion reaction?
A) Notify the healthcare provider
B) Stop the transfusion immediately
C) Take the patient's vital signs
D) Administer an antihistamine
Correct Answer: Stop the transfusion immediately
Rationale: Stopping the transfusion prevents further exposure to the antigen
causing the reaction. This is the priority action to prevent the progression of
a potentially fatal hemolytic reaction.
5. A post-operative patient is restless and confused. What is the nurse's
priority action?
A) Apply soft wrist restraints
,B) Assess the patient's oxygen saturation
C) Administer a PRN sedative
D) Call the patient's family
Correct Answer: Assess the patient's oxygen saturation
Rationale: Hypoxia is a common cause of acute confusion in post-operative
patients. Assessing oxygen saturation is the priority to rule out this life-
threatening cause before considering other interventions.
6. Which laboratory value is most concerning and requires immediate action?
A) Serum sodium of 138 mEq/L
B) Serum potassium of 6.2 mEq/L
C) Hemoglobin of 13 g/dL
D) Serum calcium of 9.2 mg/dL
Correct Answer: Serum potassium of 6.2 mEq/L
Rationale: A serum potassium of 6.2 mEq/L indicates severe hyperkalemia,
which can cause lethal cardiac dysrhythmias. This requires immediate
intervention, such as administering calcium gluconate, insulin with glucose,
or sodium polystyrene sulfonate.
7. A client reports a sudden, severe headache and vomiting. What is the
priority nursing action?
A) Administer acetaminophen for the headache
B) Assess the client's neurological status
C) Prepare the client for a CT scan
D) Lower the room lighting
, Correct Answer: Assess the client's neurological status
Rationale: A sudden, severe headache with vomiting may indicate increased
intracranial pressure or a hemorrhage. A neurological assessment is the
priority to identify any changes in level of consciousness, pupillary response,
or motor function.
8. Which patient is at the greatest risk for developing an infection?
A) A patient with diabetes and a foot ulcer
B) A patient with hypertension
C) A patient with asthma
D) A patient with a migraine
Correct Answer: A patient with diabetes and a foot ulcer
Rationale: Diabetes impairs the immune system and circulation, and a foot
ulcer provides a direct portal of entry for pathogens. This patient is at the
highest risk for infection among the options.
9. What is the priority action for a nurse during an acute exacerbation of
COPD?
A) Administer high-flow oxygen via non-rebreather mask
B) Administer low-flow oxygen via nasal cannula
C) Administer a nebulizer treatment PRN only
D) Restrict fluid intake
Correct Answer: Administer low-flow oxygen via nasal cannula
