1. A patient on a progressive care unit reports a sudden headache and
blurry vision. The nurse notes a blood pressure of 220/110 mmHg.
What is the priority action?
A. Administer a prescribed antihypertensive IV medication.
B. Recheck the blood pressure in 15 minutes.
C. Notify the healthcare provider immediately.
D. Place the patient in a semi-Fowler's position.
Answer and Rationale:
A. Administer a prescribed antihypertensive IV medication.
Rationale: Hypertensive emergencies require immediate lowering of
blood pressure to prevent organ damage.
2. A patient with type 1 diabetes has a blood glucose of 45 mg/dL and
is alert but shaky. What is the nurse’s priority intervention?
A. Administer 1 mg of glucagon IM.
B. Provide 15 g of fast-acting carbohydrates.
C. Start an IV dextrose infusion.
D. Recheck blood glucose in 15 minutes.
Answer and Rationale:
B. Provide 15 g of fast-acting carbohydrates.
,Rationale: The patient is alert, so oral carbohydrates are the
appropriate and fastest intervention for hypoglycemia.
3. A patient on telemetry exhibits a sudden onset of atrial fibrillation
with a ventricular rate of 140 bpm. What is the most appropriate initial
action by the nurse?
A. Administer an IV beta-blocker as prescribed.
B. Prepare the patient for cardioversion.
C. Assess the patient’s blood pressure and level of consciousness.
D. Notify the healthcare provider immediately.
Answer and Rationale:
C. Assess the patient’s blood pressure and level of consciousness.
Rationale: Assessment of hemodynamic stability is critical to determine
if the patient requires urgent intervention such as cardioversion or if
rate control measures can be pursued.
4. A patient develops a sudden drop in SpO2 to 85% while on oxygen at
2 L/min via nasal cannula. What is the nurse’s first action?
A. Increase the oxygen flow rate.
B. Call the Rapid Response Team.
C. Assess airway patency and breath sounds.
D. Prepare for intubation.
Answer and Rationale:
, C. Assess airway patency and breath sounds.
Rationale: Assessment is the priority to determine the cause of the
desaturation before taking further action.
5. A patient is admitted with a suspected pulmonary embolism. Which
diagnostic test does the nurse anticipate?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. Arterial blood gas (ABG)
Answer and Rationale:
C. CT pulmonary angiography
Rationale: This is the gold standard for diagnosing pulmonary
embolism.
6. A patient with cirrhosis presents with confusion and lethargy. Which
intervention should the nurse implement first?
A. Administer lactulose as prescribed.
B. Restrict dietary protein intake.
C. Check ammonia levels.
D. Monitor for signs of infection.
Answer and Rationale:
A. Administer lactulose as prescribed.
blurry vision. The nurse notes a blood pressure of 220/110 mmHg.
What is the priority action?
A. Administer a prescribed antihypertensive IV medication.
B. Recheck the blood pressure in 15 minutes.
C. Notify the healthcare provider immediately.
D. Place the patient in a semi-Fowler's position.
Answer and Rationale:
A. Administer a prescribed antihypertensive IV medication.
Rationale: Hypertensive emergencies require immediate lowering of
blood pressure to prevent organ damage.
2. A patient with type 1 diabetes has a blood glucose of 45 mg/dL and
is alert but shaky. What is the nurse’s priority intervention?
A. Administer 1 mg of glucagon IM.
B. Provide 15 g of fast-acting carbohydrates.
C. Start an IV dextrose infusion.
D. Recheck blood glucose in 15 minutes.
Answer and Rationale:
B. Provide 15 g of fast-acting carbohydrates.
,Rationale: The patient is alert, so oral carbohydrates are the
appropriate and fastest intervention for hypoglycemia.
3. A patient on telemetry exhibits a sudden onset of atrial fibrillation
with a ventricular rate of 140 bpm. What is the most appropriate initial
action by the nurse?
A. Administer an IV beta-blocker as prescribed.
B. Prepare the patient for cardioversion.
C. Assess the patient’s blood pressure and level of consciousness.
D. Notify the healthcare provider immediately.
Answer and Rationale:
C. Assess the patient’s blood pressure and level of consciousness.
Rationale: Assessment of hemodynamic stability is critical to determine
if the patient requires urgent intervention such as cardioversion or if
rate control measures can be pursued.
4. A patient develops a sudden drop in SpO2 to 85% while on oxygen at
2 L/min via nasal cannula. What is the nurse’s first action?
A. Increase the oxygen flow rate.
B. Call the Rapid Response Team.
C. Assess airway patency and breath sounds.
D. Prepare for intubation.
Answer and Rationale:
, C. Assess airway patency and breath sounds.
Rationale: Assessment is the priority to determine the cause of the
desaturation before taking further action.
5. A patient is admitted with a suspected pulmonary embolism. Which
diagnostic test does the nurse anticipate?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. Arterial blood gas (ABG)
Answer and Rationale:
C. CT pulmonary angiography
Rationale: This is the gold standard for diagnosing pulmonary
embolism.
6. A patient with cirrhosis presents with confusion and lethargy. Which
intervention should the nurse implement first?
A. Administer lactulose as prescribed.
B. Restrict dietary protein intake.
C. Check ammonia levels.
D. Monitor for signs of infection.
Answer and Rationale:
A. Administer lactulose as prescribed.
