Answers | Latest Version | 2025/2026 |
Correct & Verified
A patient reports shortness of breath after a cardiac procedure. What should the nurse do first?
A. Notify the provider immediately
✔✔B. Assess respiratory rate, oxygen saturation, and breath sounds
C. Sit with the patient to provide reassurance
D. Administer oxygen without assessment
A patient is confused and attempting to get out of bed. What is the priority nursing action?
A. Give the patient a sedative
✔✔B. Implement fall precautions and stay with the patient as needed
C. Tell the patient to wait until help arrives
D. Call security
A child is admitted with a high fever and seizure activity. What is the nurse’s first action?
✔✔Ensure the child’s safety and maintain airway during seizure
A. Call the provider after the seizure
1
,B. Begin IV antibiotics immediately
C. Measure the child’s temperature
A patient has a new prescription for an antihypertensive. What should the nurse monitor first?
A. Blood glucose
✔✔B. Blood pressure and heart rate
C. Respiratory rate
D. Oxygen saturation
A nurse observes another nurse documenting care before performing it. What is the best
response?
A. Ignore the situation
B. Report immediately to the board of nursing
✔✔C. Remind the nurse that documentation must be accurate and timely
D. Tell the patient
A postoperative patient reports severe pain. What should the nurse do first?
A. Ask the patient to wait 30 minutes
2
,B. Give the maximum dose immediately
✔✔C. Assess pain location, intensity, and characteristics
D. Call the provider before assessment
A patient is scheduled for surgery and asks why they must be NPO. What is the best nursing
response?
✔✔To reduce the risk of aspiration during anesthesia
A. To make the stomach empty faster
B. Because food interferes with anesthesia medications
C. Because fasting speeds recovery
A patient is refusing medication due to fear of side effects. What is the nurse’s best response?
✔✔Explain the benefits, risks, and purpose of the medication
A. Force the patient to take it
B. Ignore the refusal
C. Wait until the patient changes their mind
A patient with diabetes reports blood glucose of 320 mg/dL. What is the nurse’s first action?
3
, ✔✔Check for signs of hyperglycemia and notify the provider
A. Give insulin without assessment
B. Encourage the patient to drink fluids only
C. Ignore the reading
A patient develops a rash after receiving IV antibiotics. What should the nurse do first?
✔✔Stop the infusion and notify the provider
A. Apply a topical cream
B. Continue infusion while monitoring
C. Document only
A patient reports dizziness when standing. What is the priority nursing action?
✔✔Assist the patient to sit or lie down and assess vital signs
A. Tell the patient to ignore it
B. Increase IV fluids immediately
C. Administer antihypertensives
A patient has a Foley catheter and reports bladder spasms. What should the nurse do first?
4