Answers | Latest Version | 2025/2026 |
Correct & Verified
A patient reports shortness of breath and wheezing. What is the nurse’s first action?
✔✔Assess respiratory status and administer prescribed bronchodilator.
A patient postoperatively has a sudden drop in blood pressure. What should the nurse do first?
✔✔Assess for signs of bleeding and notify the provider immediately.
A client is scheduled for surgery and asks why NPO status is required. What is the nurse’s best
response?
✔✔Explain that fasting reduces the risk of aspiration during anesthesia.
A patient is confused and trying to leave the bed unassisted. What is the priority intervention?
✔✔Implement fall precautions and stay with the patient as needed.
A patient with a history of diabetes has a blood glucose of 60 mg/dL and is symptomatic. What is
the first nursing action?
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,✔✔Administer a fast-acting carbohydrate and recheck blood glucose.
A patient complains of severe chest pain radiating to the left arm. What should the nurse do first?
✔✔Assess vital signs, apply continuous cardiac monitoring, and notify the provider.
A patient with a new prescription for diuretics reports dizziness. What is the first nursing action?
✔✔Assess blood pressure and heart rate before administering the medication.
A patient develops a rash after starting antibiotics. What is the priority action?
✔✔Stop the medication and notify the provider of a potential allergic reaction.
A patient reports sudden onset of severe headache and vision changes. What should the nurse do
first?
✔✔Assess neurological status and notify the provider immediately.
A patient has postoperative pain that is not relieved by medication. What should the nurse do
first?
✔✔Assess the pain characteristics and evaluate for potential complications.
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,A patient is experiencing shortness of breath and cyanosis. What is the first nursing action?
✔✔Administer oxygen and assess oxygen saturation.
A patient reports nausea and vomiting after chemotherapy. What should the nurse do first?
✔✔Assess severity and administer prescribed antiemetics.
A patient with a Foley catheter reports bladder spasms. What should the nurse assess first?
✔✔Check for kinks in the catheter and ensure proper placement.
A patient with heart failure has gained 3 pounds in 2 days. What is the first nursing action?
✔✔Assess for edema and review fluid status with the provider.
A patient shows signs of hypoglycemia after insulin administration. What is the nurse’s priority
action?
✔✔Administer a rapid-acting glucose source and monitor blood glucose.
A patient has new-onset confusion and fever. What is the nurse’s first intervention?
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, ✔✔Assess vital signs and notify the provider for possible infection.
A patient with a history of asthma reports increased wheezing at night. What is the priority
nursing action?
✔✔Assess lung sounds and administer a prescribed rescue inhaler.
A patient reports burning on urination. What should the nurse do first?
✔✔Assess for urinary tract infection and collect a urine sample if indicated.
A postoperative patient has tachycardia and hypotension. What is the first nursing action?
✔✔Assess for bleeding and ensure IV access for fluid replacement.
A patient receiving IV therapy has redness and swelling at the site. What is the first nursing
action?
✔✔Stop the IV, remove the catheter, and apply a sterile dressing.
A patient reports numbness and tingling after starting a new medication. What is the nurse’s first
action?
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