Professional Nursing & Clinical Judgment EXAM with 200 Questions
and Answers | Updated 2026 A+ | Instant Download PDF
Table of Contents
1. Clinical Assessment and Prioritization
2. Patient Safety and Risk Management
3. Clinical Decision-Making and Delegation
4. Acute Care, Communication, and Interprofessional Practice
1. Clinical Assessment and Prioritization
1. A postoperative patient suddenly becomes restless, tachypneic, and cyanotic with an oxygen
saturation of 84% despite oxygen at 4 L/min via nasal cannula; what should the nurse do
first?
A. Obtain a complete pain assessment
B. Assess airway and breathing while activating immediate assistance
C. Administer the prescribed opioid analgesic
D. Reassure the patient that anxiety can cause dyspnea
Answer: B
Rationale: Immediate assessment and escalation address potentially life-threatening airway
or respiratory compromise before less urgent interventions.
2. A patient with heart failure has gained 2.5 kg in three days and reports increasing
orthopnea; which finding requires the most immediate nursing action?
A. Mild bilateral ankle edema
B. Fatigue after walking
C. New crackles with an oxygen saturation of 88%
D. Reduced appetite
Answer: C
Rationale: Hypoxemia with pulmonary crackles suggests worsening pulmonary congestion
requiring prompt intervention.
3. A nurse assesses a patient with suspected sepsis who has a temperature of 39.2°C, blood
pressure of 86/50 mmHg, heart rate of 128/min, and altered mentation; which action has
priority?
A. Encourage oral fluids
B. Administer an antipyretic and reassess in one hour
C. Initiate the facility's sepsis response and obtain ordered cultures and lactate promptly
D. Place the patient in a quiet room
Answer: C
Rationale: Hypotension, tachycardia, fever, and altered mentation indicate possible septic
shock requiring rapid bundle-based management.
4. A patient with diabetes is confused, diaphoretic, and shaky; bedside glucose is 2.4 mmol/L
(43 mg/dL), and the patient can swallow safely; what is the priority intervention?
A. Administer long-acting insulin
B. Give a rapid-acting oral glucose source
, C. Restrict oral intake
D. Administer the patient's scheduled meal insulin
Answer: B
Rationale: Conscious patients with symptomatic hypoglycemia who can swallow should
receive rapidly absorbable glucose.
5. A patient receiving a blood transfusion develops chills, fever, back pain, and dyspnea; what
should the nurse do first?
A. Slow the transfusion
B. Administer an antipyretic
C. Stop the transfusion and maintain IV access with compatible fluid according to protocol
D. Continue the transfusion while obtaining vital signs
Answer: C
Rationale: The findings may indicate an acute transfusion reaction, requiring immediate
discontinuation of the blood product.
6. A patient with chronic obstructive pulmonary disease becomes increasingly somnolent after
receiving supplemental oxygen; which assessment is most important?
A. Dietary intake
B. Respiratory rate, effort, and carbon dioxide retention indicators
C. Skin turgor
D. Bowel sounds
Answer: B
Rationale: Increasing somnolence may reflect worsening hypercapnia or respiratory failure
requiring immediate respiratory assessment.
7. A patient reports crushing chest pressure radiating to the jaw with nausea; which nursing
action is most appropriate initially?
A. Encourage ambulation to assess tolerance
B. Obtain vital signs and initiate the acute coronary syndrome protocol
C. Give an oral antacid and reassess later
D. Ask the patient to wait until the physician arrives
Answer: B
Rationale: The symptoms are concerning for acute coronary syndrome and require rapid
assessment and protocol-driven treatment.
8. A patient with a head injury becomes increasingly confused and develops unequal pupils;
what is the nurse's priority?
A. Reduce environmental stimulation only
B. Offer oral fluids
C. Perform an immediate neurologic assessment and activate emergency evaluation
D. Administer a prescribed sleep medication
Answer: C
Rationale: Acute neurologic deterioration and anisocoria may indicate rising intracranial
pressure or herniation.
9. A patient receiving an opioid becomes difficult to arouse with a respiratory rate of 7/min;
which intervention takes priority?
A. Document the sedation score
B. Support ventilation and administer naloxone as prescribed or per emergency protocol
, C. Give another dose of analgesic
D. Encourage the patient to sleep
Answer: B
Rationale: Severe opioid-induced respiratory depression requires immediate airway and
ventilatory support with opioid reversal when indicated.
10. A patient with acute kidney injury has potassium of 6.7 mmol/L and peaked T waves on ECG;
which action should the nurse prioritize?
A. Encourage potassium-rich foods
B. Recheck the potassium tomorrow
C. Initiate cardiac monitoring and urgently implement hyperkalemia treatment orders
D. Administer a potassium supplement
Answer: C
Rationale: Severe hyperkalemia with ECG changes can rapidly cause fatal dysrhythmias.
11. A patient with suspected stroke developed facial drooping and aphasia 45 minutes ago;
what should the nurse prioritize?
A. Give oral fluids
B. Activate the stroke pathway and establish the time last known well
C. Place the patient in Trendelenburg position
D. Delay assessment until family arrives
Answer: B
Rationale: Stroke treatment decisions are highly time dependent, making rapid activation
and determination of symptom onset essential.
12. A patient with severe asthma has increasing respiratory distress and becomes suddenly
quieter on auscultation; how should the nurse interpret this finding?
A. Improvement from reduced wheezing
B. Possible critically reduced airflow requiring emergency intervention
C. Expected response to bronchodilator therapy
D. Anxiety resolution
Answer: B
Rationale: A silent chest during severe asthma can indicate minimal airflow and impending
respiratory failure.
13. A postoperative patient has urine output of 15 mL over two hours and a blood pressure of
88/54 mmHg; what should the nurse do first?
A. Restrict fluids
B. Assess perfusion and promptly notify the provider or rapid-response team as indicated
C. Administer a diuretic independently
D. Document the output as expected
Answer: B
Rationale: Oliguria with hypotension may indicate inadequate renal perfusion or shock
requiring urgent evaluation.
14. A patient with pneumonia has increasing work of breathing and an oxygen saturation of 86%
despite prescribed oxygen; which action is most appropriate?
A. Encourage uninterrupted sleep
B. Reassess respiratory status and escalate oxygen/respiratory support according to
protocol
, C. Remove the oxygen temporarily
D. Encourage oral fluids before reassessment
Answer: B
Rationale: Persistent hypoxemia despite oxygen indicates deterioration requiring immediate
reassessment and escalation.
15. A patient with cirrhosis develops hematemesis, tachycardia, and hypotension; which nursing
action has the highest priority?
A. Provide a high-protein meal
B. Protect the airway, establish or maintain large-bore IV access, and initiate emergency
management
C. Encourage ambulation
D. Administer oral medications
Answer: B
Rationale: Massive upper gastrointestinal bleeding creates immediate airway and circulatory
threats.
16. A patient with suspected pulmonary embolism suddenly develops dyspnea, pleuritic chest
pain, and tachycardia; what should the nurse do?
A. Encourage walking
B. Provide oxygen, assess hemodynamic status, and activate urgent medical evaluation
C. Place the patient flat without assessment
D. Give oral fluids
Answer: B
Rationale: Acute respiratory and circulatory compromise from suspected pulmonary
embolism requires immediate stabilization and evaluation.
17. A patient with severe dehydration has a heart rate of 132/min, weak pulses, and delayed
capillary refill; which finding most strongly indicates worsening shock?
A. Dry lips
B. Thirst
C. Altered mental status with persistent hypotension
D. Mild nausea
Answer: C
Rationale: Altered mentation and hypotension indicate inadequate cerebral and systemic
perfusion.
18. A patient receiving IV antibiotics develops wheezing, facial swelling, and hypotension; which
medication should the nurse anticipate as the priority treatment?
A. Acetaminophen
B. Furosemide
C. Epinephrine
D. Oral antihistamine only
Answer: C
Rationale: Airway compromise and hypotension indicate anaphylaxis for which intramuscular
epinephrine is first-line treatment.
19. A patient with diabetic ketoacidosis has deep respirations and altered consciousness; which
assessment is most urgent?
A. Skin color only
and Answers | Updated 2026 A+ | Instant Download PDF
Table of Contents
1. Clinical Assessment and Prioritization
2. Patient Safety and Risk Management
3. Clinical Decision-Making and Delegation
4. Acute Care, Communication, and Interprofessional Practice
1. Clinical Assessment and Prioritization
1. A postoperative patient suddenly becomes restless, tachypneic, and cyanotic with an oxygen
saturation of 84% despite oxygen at 4 L/min via nasal cannula; what should the nurse do
first?
A. Obtain a complete pain assessment
B. Assess airway and breathing while activating immediate assistance
C. Administer the prescribed opioid analgesic
D. Reassure the patient that anxiety can cause dyspnea
Answer: B
Rationale: Immediate assessment and escalation address potentially life-threatening airway
or respiratory compromise before less urgent interventions.
2. A patient with heart failure has gained 2.5 kg in three days and reports increasing
orthopnea; which finding requires the most immediate nursing action?
A. Mild bilateral ankle edema
B. Fatigue after walking
C. New crackles with an oxygen saturation of 88%
D. Reduced appetite
Answer: C
Rationale: Hypoxemia with pulmonary crackles suggests worsening pulmonary congestion
requiring prompt intervention.
3. A nurse assesses a patient with suspected sepsis who has a temperature of 39.2°C, blood
pressure of 86/50 mmHg, heart rate of 128/min, and altered mentation; which action has
priority?
A. Encourage oral fluids
B. Administer an antipyretic and reassess in one hour
C. Initiate the facility's sepsis response and obtain ordered cultures and lactate promptly
D. Place the patient in a quiet room
Answer: C
Rationale: Hypotension, tachycardia, fever, and altered mentation indicate possible septic
shock requiring rapid bundle-based management.
4. A patient with diabetes is confused, diaphoretic, and shaky; bedside glucose is 2.4 mmol/L
(43 mg/dL), and the patient can swallow safely; what is the priority intervention?
A. Administer long-acting insulin
B. Give a rapid-acting oral glucose source
, C. Restrict oral intake
D. Administer the patient's scheduled meal insulin
Answer: B
Rationale: Conscious patients with symptomatic hypoglycemia who can swallow should
receive rapidly absorbable glucose.
5. A patient receiving a blood transfusion develops chills, fever, back pain, and dyspnea; what
should the nurse do first?
A. Slow the transfusion
B. Administer an antipyretic
C. Stop the transfusion and maintain IV access with compatible fluid according to protocol
D. Continue the transfusion while obtaining vital signs
Answer: C
Rationale: The findings may indicate an acute transfusion reaction, requiring immediate
discontinuation of the blood product.
6. A patient with chronic obstructive pulmonary disease becomes increasingly somnolent after
receiving supplemental oxygen; which assessment is most important?
A. Dietary intake
B. Respiratory rate, effort, and carbon dioxide retention indicators
C. Skin turgor
D. Bowel sounds
Answer: B
Rationale: Increasing somnolence may reflect worsening hypercapnia or respiratory failure
requiring immediate respiratory assessment.
7. A patient reports crushing chest pressure radiating to the jaw with nausea; which nursing
action is most appropriate initially?
A. Encourage ambulation to assess tolerance
B. Obtain vital signs and initiate the acute coronary syndrome protocol
C. Give an oral antacid and reassess later
D. Ask the patient to wait until the physician arrives
Answer: B
Rationale: The symptoms are concerning for acute coronary syndrome and require rapid
assessment and protocol-driven treatment.
8. A patient with a head injury becomes increasingly confused and develops unequal pupils;
what is the nurse's priority?
A. Reduce environmental stimulation only
B. Offer oral fluids
C. Perform an immediate neurologic assessment and activate emergency evaluation
D. Administer a prescribed sleep medication
Answer: C
Rationale: Acute neurologic deterioration and anisocoria may indicate rising intracranial
pressure or herniation.
9. A patient receiving an opioid becomes difficult to arouse with a respiratory rate of 7/min;
which intervention takes priority?
A. Document the sedation score
B. Support ventilation and administer naloxone as prescribed or per emergency protocol
, C. Give another dose of analgesic
D. Encourage the patient to sleep
Answer: B
Rationale: Severe opioid-induced respiratory depression requires immediate airway and
ventilatory support with opioid reversal when indicated.
10. A patient with acute kidney injury has potassium of 6.7 mmol/L and peaked T waves on ECG;
which action should the nurse prioritize?
A. Encourage potassium-rich foods
B. Recheck the potassium tomorrow
C. Initiate cardiac monitoring and urgently implement hyperkalemia treatment orders
D. Administer a potassium supplement
Answer: C
Rationale: Severe hyperkalemia with ECG changes can rapidly cause fatal dysrhythmias.
11. A patient with suspected stroke developed facial drooping and aphasia 45 minutes ago;
what should the nurse prioritize?
A. Give oral fluids
B. Activate the stroke pathway and establish the time last known well
C. Place the patient in Trendelenburg position
D. Delay assessment until family arrives
Answer: B
Rationale: Stroke treatment decisions are highly time dependent, making rapid activation
and determination of symptom onset essential.
12. A patient with severe asthma has increasing respiratory distress and becomes suddenly
quieter on auscultation; how should the nurse interpret this finding?
A. Improvement from reduced wheezing
B. Possible critically reduced airflow requiring emergency intervention
C. Expected response to bronchodilator therapy
D. Anxiety resolution
Answer: B
Rationale: A silent chest during severe asthma can indicate minimal airflow and impending
respiratory failure.
13. A postoperative patient has urine output of 15 mL over two hours and a blood pressure of
88/54 mmHg; what should the nurse do first?
A. Restrict fluids
B. Assess perfusion and promptly notify the provider or rapid-response team as indicated
C. Administer a diuretic independently
D. Document the output as expected
Answer: B
Rationale: Oliguria with hypotension may indicate inadequate renal perfusion or shock
requiring urgent evaluation.
14. A patient with pneumonia has increasing work of breathing and an oxygen saturation of 86%
despite prescribed oxygen; which action is most appropriate?
A. Encourage uninterrupted sleep
B. Reassess respiratory status and escalate oxygen/respiratory support according to
protocol
, C. Remove the oxygen temporarily
D. Encourage oral fluids before reassessment
Answer: B
Rationale: Persistent hypoxemia despite oxygen indicates deterioration requiring immediate
reassessment and escalation.
15. A patient with cirrhosis develops hematemesis, tachycardia, and hypotension; which nursing
action has the highest priority?
A. Provide a high-protein meal
B. Protect the airway, establish or maintain large-bore IV access, and initiate emergency
management
C. Encourage ambulation
D. Administer oral medications
Answer: B
Rationale: Massive upper gastrointestinal bleeding creates immediate airway and circulatory
threats.
16. A patient with suspected pulmonary embolism suddenly develops dyspnea, pleuritic chest
pain, and tachycardia; what should the nurse do?
A. Encourage walking
B. Provide oxygen, assess hemodynamic status, and activate urgent medical evaluation
C. Place the patient flat without assessment
D. Give oral fluids
Answer: B
Rationale: Acute respiratory and circulatory compromise from suspected pulmonary
embolism requires immediate stabilization and evaluation.
17. A patient with severe dehydration has a heart rate of 132/min, weak pulses, and delayed
capillary refill; which finding most strongly indicates worsening shock?
A. Dry lips
B. Thirst
C. Altered mental status with persistent hypotension
D. Mild nausea
Answer: C
Rationale: Altered mentation and hypotension indicate inadequate cerebral and systemic
perfusion.
18. A patient receiving IV antibiotics develops wheezing, facial swelling, and hypotension; which
medication should the nurse anticipate as the priority treatment?
A. Acetaminophen
B. Furosemide
C. Epinephrine
D. Oral antihistamine only
Answer: C
Rationale: Airway compromise and hypotension indicate anaphylaxis for which intramuscular
epinephrine is first-line treatment.
19. A patient with diabetic ketoacidosis has deep respirations and altered consciousness; which
assessment is most urgent?
A. Skin color only
