1. Clinical Judgment and Decision Making
1. A 68-year-old client reports sudden onset of crushing
chest pain radiating to the left arm. Which finding
should the nurse recognize as the most urgent cue?
A. Blood pressure 138/82 mm Hg
B. Irregular, thready pulse of 54 beats/min
C. Skin cool and diaphoretic
D. Client’s report of pain rated 9/10
Correct Answer: B
Rationale: A thready, irregular pulse suggests
decreased cardiac output and possible dysrhythmia
requiring immediate intervention (UbiSim).
2. A client with chronic obstructive pulmonary disease
has SpO₂ of 86% on room air. Which action should
the nurse take first?
A. Call the respiratory therapist
B. Apply 2 L/min oxygen via nasal cannula
C. Elevate the head of the bed
D. Encourage pursed‐lips breathing
Correct Answer: C
Rationale: Elevating the head improves lung
expansion and gas exchange immediately,
addressing hypoxemia (UbiSim).
3. A postoperative client’s surgical wound shows a 3 cm
area of partial slough with surrounding erythema.
What is the nurse’s priority action?
, A. Send wound culture
B. Reinforce dressing
C. Document findings
D. Notify the surgeon
Correct Answer: B
Rationale: Reinforcing the dressing addresses
possible exudate leakage and prevents further tissue
damage while other actions are arranged (UbiSim).
4. A client receiving chemotherapy reports fatigue,
pallor, and tachycardia. Which lab result supports the
nurse’s suspicion of anemia?
A. WBC 4,500 cells/mm³
B. Hct 28%
C. Platelets 150,000 cells/mm³
D. ANC 1,800 cells/mm³
Correct Answer: B
Rationale: Hematocrit of 28% is below normal,
indicating anemia consistent with symptoms (UbiSim).
5. A diabetic client’s glucometer reads 52 mg/dL. Which
nursing action has highest priority?
A. Administer 4 oz orange juice
B. Recheck in 15 minutes
C. Call the provider
D. Encourage client to eat a meal
Correct Answer: A
Rationale: Immediate glucose replacement
addresses hypoglycemia and prevents
neuroglycopenic complications (UbiSim).
, 6. A client develops sudden shortness of breath and
pleuritic chest pain on postoperative day 2. Which
sign is most concerning?
A. Respiratory rate 28/min
B. O₂ saturation 92%
C. Sharp chest pain on inspiration
D. Unilateral calf swelling
Correct Answer: D
Rationale: Calf swelling suggests deep vein
thrombosis with risk of pulmonary embolism requiring
emergent evaluation (UbiSim).
7. A client with heart failure has an acute weight gain of
4 lb in 24 hours. Which finding should the nurse report
first?
A. 2+ pitting edema in ankles
B. Blood pressure 160/90 mm Hg
C. Crackles in lower lung fields
D. Urine output 800 mL/24 hours
Correct Answer: C
Rationale: Crackles indicate fluid overload in lungs
(pulmonary edema), an immediate threat to
oxygenation (UbiSim).
8. A client admitted with diabetic ketoacidosis (DKA) has
K⁺ 3.2 mEq/L. Which intervention should the nurse
perform?
A. Initiate potassium replacement
B. Restrict dietary potassium
C. Start insulin infusion
1. A 68-year-old client reports sudden onset of crushing
chest pain radiating to the left arm. Which finding
should the nurse recognize as the most urgent cue?
A. Blood pressure 138/82 mm Hg
B. Irregular, thready pulse of 54 beats/min
C. Skin cool and diaphoretic
D. Client’s report of pain rated 9/10
Correct Answer: B
Rationale: A thready, irregular pulse suggests
decreased cardiac output and possible dysrhythmia
requiring immediate intervention (UbiSim).
2. A client with chronic obstructive pulmonary disease
has SpO₂ of 86% on room air. Which action should
the nurse take first?
A. Call the respiratory therapist
B. Apply 2 L/min oxygen via nasal cannula
C. Elevate the head of the bed
D. Encourage pursed‐lips breathing
Correct Answer: C
Rationale: Elevating the head improves lung
expansion and gas exchange immediately,
addressing hypoxemia (UbiSim).
3. A postoperative client’s surgical wound shows a 3 cm
area of partial slough with surrounding erythema.
What is the nurse’s priority action?
, A. Send wound culture
B. Reinforce dressing
C. Document findings
D. Notify the surgeon
Correct Answer: B
Rationale: Reinforcing the dressing addresses
possible exudate leakage and prevents further tissue
damage while other actions are arranged (UbiSim).
4. A client receiving chemotherapy reports fatigue,
pallor, and tachycardia. Which lab result supports the
nurse’s suspicion of anemia?
A. WBC 4,500 cells/mm³
B. Hct 28%
C. Platelets 150,000 cells/mm³
D. ANC 1,800 cells/mm³
Correct Answer: B
Rationale: Hematocrit of 28% is below normal,
indicating anemia consistent with symptoms (UbiSim).
5. A diabetic client’s glucometer reads 52 mg/dL. Which
nursing action has highest priority?
A. Administer 4 oz orange juice
B. Recheck in 15 minutes
C. Call the provider
D. Encourage client to eat a meal
Correct Answer: A
Rationale: Immediate glucose replacement
addresses hypoglycemia and prevents
neuroglycopenic complications (UbiSim).
, 6. A client develops sudden shortness of breath and
pleuritic chest pain on postoperative day 2. Which
sign is most concerning?
A. Respiratory rate 28/min
B. O₂ saturation 92%
C. Sharp chest pain on inspiration
D. Unilateral calf swelling
Correct Answer: D
Rationale: Calf swelling suggests deep vein
thrombosis with risk of pulmonary embolism requiring
emergent evaluation (UbiSim).
7. A client with heart failure has an acute weight gain of
4 lb in 24 hours. Which finding should the nurse report
first?
A. 2+ pitting edema in ankles
B. Blood pressure 160/90 mm Hg
C. Crackles in lower lung fields
D. Urine output 800 mL/24 hours
Correct Answer: C
Rationale: Crackles indicate fluid overload in lungs
(pulmonary edema), an immediate threat to
oxygenation (UbiSim).
8. A client admitted with diabetic ketoacidosis (DKA) has
K⁺ 3.2 mEq/L. Which intervention should the nurse
perform?
A. Initiate potassium replacement
B. Restrict dietary potassium
C. Start insulin infusion
