Answers | Latest Version | 2025/2026 |
Correct & Verified
A patient reports chest pain radiating to the arm. What is the nurse’s first action?
A. Give analgesics immediately
B. Document the report
✔✔C. Assess vital signs and apply cardiac monitoring
D. Sit patient upright
A patient is confused and trying to get out of bed unassisted. What should the nurse do first?
A. Call security
✔✔B. Implement fall precautions and provide supervision
C. Give a sedative
D. Tell the patient to wait
A patient has a Foley catheter and reports bladder spasms. What is the priority action?
A. Remove the catheter
✔✔B. Check for kinks and ensure patency
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,C. Notify family
D. Give pain medication only
A child presents with a high fever and seizure activity. What should the nurse do first?
A. Administer antipyretics
✔✔B. Ensure safety and maintain airway
C. Call the provider after seizure
D. Document only
A patient’s blood glucose is 320 mg/dL. What is the nurse’s first action?
✔✔A. Assess for signs of hyperglycemia and notify provider
B. Give insulin immediately
C. Encourage oral fluids only
D. Ignore the reading
A postoperative patient reports shortness of breath and low oxygen saturation. What should the
nurse do first?
A. Sit with the patient
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,B. Encourage coughing and deep breathing
✔✔C. Administer oxygen and assess airway
D. Document symptoms
A patient reports dizziness when standing. What is the priority nursing action?
✔✔A. Assist patient to sit or lie down and assess vital signs
B. Increase IV fluids immediately
C. Tell the patient to ignore it
D. Document
A patient refuses a newly prescribed medication. What is the nurse’s best response?
A. Force the patient to take it
✔✔B. Explain the benefits, risks, and purpose of the medication
C. Ignore the refusal
D. Wait until the patient changes their mind
A patient develops a rash after IV antibiotics. What should the nurse do first?
A. Apply a topical cream
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, B. Continue the infusion
✔✔C. Stop the infusion and notify the provider
D. Document only
A patient reports numbness and tingling in hands after starting a new medication. What should
the nurse do first?
A. Tell the patient it is normal
✔✔B. Assess for adverse drug reaction and notify the provider
C. Wait for next assessment
D. Document only
A patient is scheduled for surgery and asks why NPO status is required. What is the nurse’s best
response?
A. To speed recovery
B. To make the stomach empty faster
✔✔C. To reduce risk of aspiration during anesthesia
D. Because it interferes with anesthesia
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