1. A nurse is caring for a patient who is experiencing acute pain after
surgery. Which of the following is the most appropriate first action to
manage this patient’s pain?
A. Administer the prescribed pain medication
B. Assess the patient's pain level
C. Apply heat to the surgical site
D. Notify the healthcare provider about the pain
Answer: B. Assess the patient's pain level
Rationale: The first step in pain management is to assess the patient's
pain level using a standardized pain scale. This allows the nurse to
understand the intensity, location, and nature of the pain, which helps
guide further interventions such as medication administration or non-
pharmacologic strategies.
2. A nurse is preparing to discharge a patient with a new diagnosis of
diabetes mellitus. Which of the following should the nurse include in
the discharge teaching?
A. "You can eat any food, but avoid foods with carbohydrates."
B. "You should monitor your blood glucose levels every 2 days."
C. "You will need to monitor your blood glucose regularly and adjust
your diet."
D. "If your blood glucose is too high, take a double dose of your insulin."
Answer: C. "You will need to monitor your blood glucose regularly and
adjust your diet."
Rationale: For diabetes management, the patient should monitor blood
glucose levels regularly, adjust their diet, and take insulin as needed.
,Teaching the patient to monitor blood glucose frequently and maintain
a balanced diet is essential to avoid complications.
3. A nurse is caring for a patient who has been diagnosed with acute
kidney injury (AKI). Which of the following laboratory findings would
most likely be elevated in this patient?
A. Hemoglobin
B. Blood urea nitrogen (BUN)
C. Serum calcium
D. Potassium
Answer: B. Blood urea nitrogen (BUN)
Rationale: In acute kidney injury (AKI), kidney function is impaired,
leading to a buildup of waste products like BUN and creatinine in the
blood. Elevated BUN levels are a hallmark sign of kidney dysfunction.
Elevated potassium may also occur, but BUN is a more specific indicator
in this scenario.
4. A nurse is providing care to a patient who has a history of chronic
obstructive pulmonary disease (COPD) and is currently experiencing
an acute exacerbation. Which of the following interventions should
the nurse prioritize?
A. Administer a beta-agonist bronchodilator
B. Instruct the patient to take deep breaths and cough
C. Provide oxygen therapy via nasal cannula
D. Monitor vital signs every 2 hours
Answer: A. Administer a beta-agonist bronchodilator
,Rationale: During an acute exacerbation of COPD, the priority
intervention is to administer a bronchodilator (e.g., albuterol) to relax
the smooth muscles of the airways and improve airflow. Oxygen
therapy and deep breathing exercises are also important, but
bronchodilation should come first in acute exacerbations.
5. A nurse is assessing a patient who has a central venous catheter
(CVC) in place. The nurse notes that the patient’s neck veins are
distended. Which of the following actions should the nurse take next?
A. Increase the infusion rate of the IV fluids
B. Turn the patient onto the left side
C. Elevate the head of the bed
D. Call the healthcare provider to remove the CVC
Answer: C. Elevate the head of the bed
Rationale: Distended neck veins can indicate fluid overload or elevated
central venous pressure. Elevating the head of the bed helps reduce
venous pressure and assists with breathing. The nurse should assess
further but should prioritize reducing venous pressure by positioning
the patient appropriately.
6. A nurse is caring for a patient who has a seizure. Which of the
following actions should the nurse take first?
A. Place a tongue depressor in the patient's mouth
B. Loosen any tight clothing around the neck
C. Stay with the patient and protect them from injury
D. Call for help immediately
Answer: C. Stay with the patient and protect them from injury
, Rationale: During a seizure, the priority action is to stay with the
patient and ensure their safety. Protecting the patient from injury is the
most immediate concern, such as placing them on the floor in a safe
position. The use of a tongue depressor or other interventions should
be avoided, as they can cause harm.
7. A nurse is caring for a patient with a history of heart failure who is
receiving a loop diuretic. Which of the following findings should the
nurse report to the healthcare provider immediately?
A. Serum potassium level of 4.0 mEq/L
B. Blood pressure of 110/70 mmHg
C. Weight gain of 2 pounds in 24 hours
D. Output of 200 mL in the past 8 hours
Answer: C. Weight gain of 2 pounds in 24 hours
Rationale: A weight gain of 2 pounds (0.9 kg) in 24 hours is significant
and could indicate fluid retention, which may signal worsening heart
failure. This requires prompt evaluation and intervention. The other
findings are not as urgent.
8. A nurse is teaching a patient with hypertension about lifestyle
modifications. Which of the following should the nurse include in the
teaching?
A. "Limit your alcohol intake to no more than three drinks per day."
B. "Engage in moderate-intensity exercise for at least 30 minutes, 3 days
per week."
C. "It is important to increase your sodium intake to help manage blood
surgery. Which of the following is the most appropriate first action to
manage this patient’s pain?
A. Administer the prescribed pain medication
B. Assess the patient's pain level
C. Apply heat to the surgical site
D. Notify the healthcare provider about the pain
Answer: B. Assess the patient's pain level
Rationale: The first step in pain management is to assess the patient's
pain level using a standardized pain scale. This allows the nurse to
understand the intensity, location, and nature of the pain, which helps
guide further interventions such as medication administration or non-
pharmacologic strategies.
2. A nurse is preparing to discharge a patient with a new diagnosis of
diabetes mellitus. Which of the following should the nurse include in
the discharge teaching?
A. "You can eat any food, but avoid foods with carbohydrates."
B. "You should monitor your blood glucose levels every 2 days."
C. "You will need to monitor your blood glucose regularly and adjust
your diet."
D. "If your blood glucose is too high, take a double dose of your insulin."
Answer: C. "You will need to monitor your blood glucose regularly and
adjust your diet."
Rationale: For diabetes management, the patient should monitor blood
glucose levels regularly, adjust their diet, and take insulin as needed.
,Teaching the patient to monitor blood glucose frequently and maintain
a balanced diet is essential to avoid complications.
3. A nurse is caring for a patient who has been diagnosed with acute
kidney injury (AKI). Which of the following laboratory findings would
most likely be elevated in this patient?
A. Hemoglobin
B. Blood urea nitrogen (BUN)
C. Serum calcium
D. Potassium
Answer: B. Blood urea nitrogen (BUN)
Rationale: In acute kidney injury (AKI), kidney function is impaired,
leading to a buildup of waste products like BUN and creatinine in the
blood. Elevated BUN levels are a hallmark sign of kidney dysfunction.
Elevated potassium may also occur, but BUN is a more specific indicator
in this scenario.
4. A nurse is providing care to a patient who has a history of chronic
obstructive pulmonary disease (COPD) and is currently experiencing
an acute exacerbation. Which of the following interventions should
the nurse prioritize?
A. Administer a beta-agonist bronchodilator
B. Instruct the patient to take deep breaths and cough
C. Provide oxygen therapy via nasal cannula
D. Monitor vital signs every 2 hours
Answer: A. Administer a beta-agonist bronchodilator
,Rationale: During an acute exacerbation of COPD, the priority
intervention is to administer a bronchodilator (e.g., albuterol) to relax
the smooth muscles of the airways and improve airflow. Oxygen
therapy and deep breathing exercises are also important, but
bronchodilation should come first in acute exacerbations.
5. A nurse is assessing a patient who has a central venous catheter
(CVC) in place. The nurse notes that the patient’s neck veins are
distended. Which of the following actions should the nurse take next?
A. Increase the infusion rate of the IV fluids
B. Turn the patient onto the left side
C. Elevate the head of the bed
D. Call the healthcare provider to remove the CVC
Answer: C. Elevate the head of the bed
Rationale: Distended neck veins can indicate fluid overload or elevated
central venous pressure. Elevating the head of the bed helps reduce
venous pressure and assists with breathing. The nurse should assess
further but should prioritize reducing venous pressure by positioning
the patient appropriately.
6. A nurse is caring for a patient who has a seizure. Which of the
following actions should the nurse take first?
A. Place a tongue depressor in the patient's mouth
B. Loosen any tight clothing around the neck
C. Stay with the patient and protect them from injury
D. Call for help immediately
Answer: C. Stay with the patient and protect them from injury
, Rationale: During a seizure, the priority action is to stay with the
patient and ensure their safety. Protecting the patient from injury is the
most immediate concern, such as placing them on the floor in a safe
position. The use of a tongue depressor or other interventions should
be avoided, as they can cause harm.
7. A nurse is caring for a patient with a history of heart failure who is
receiving a loop diuretic. Which of the following findings should the
nurse report to the healthcare provider immediately?
A. Serum potassium level of 4.0 mEq/L
B. Blood pressure of 110/70 mmHg
C. Weight gain of 2 pounds in 24 hours
D. Output of 200 mL in the past 8 hours
Answer: C. Weight gain of 2 pounds in 24 hours
Rationale: A weight gain of 2 pounds (0.9 kg) in 24 hours is significant
and could indicate fluid retention, which may signal worsening heart
failure. This requires prompt evaluation and intervention. The other
findings are not as urgent.
8. A nurse is teaching a patient with hypertension about lifestyle
modifications. Which of the following should the nurse include in the
teaching?
A. "Limit your alcohol intake to no more than three drinks per day."
B. "Engage in moderate-intensity exercise for at least 30 minutes, 3 days
per week."
C. "It is important to increase your sodium intake to help manage blood
