CRITICAL THINKING CLINICAL REASONING TEST 2025/2026
QUESTIONS WITH ANSWERS GRADED A+
✔✔The nursing student is asked to describe the correct steps for performing adult
cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of
priority. All options must be used. - ✔✔Initiate breathing
Open the client's airway.
Determine unconsciousness by shaking the client and asking, "Are you OK?"
Perform chest compressions.
✔✔A client presents to the emergency department with upper gastrointestinal (GI)
bleeding and is in moderate distress. Which nursing action should be the priority for this
client? - ✔✔Determine vital signs.
✔✔The nurse is assisting in monitoring the condition of a client after pericardiocentesis
for cardiac tamponade. Which observation indicates that the procedure was
unsuccessful? - ✔✔Distant and muffled heart sounds
✔✔A client is receiving thrombolytic therapy by continuous infusion. The client suddenly
becomes extremely anxious and complains of itching. The nurse hears stridor, and on
examination of the client, notes generalized urticaria and hypotension. Which should be
the priority action of the nurse? - ✔✔Stop the infusion, and notify the registered nurse.
✔✔A family of a spinal cord-injured client rushes to the nursing station, saying that the
client needs immediate help. On entering the room, the nurse notes that the client is
diaphoretic, with a flushed face and neck, and complains of a severe headache. The
pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts
quickly, knowing that the client is experiencing which condition? - ✔✔Autonomic
dysreflexia
✔✔A client who has been receiving total parenteral nutrition by way of a central venous
access device complains of chest pain and dyspnea. The nurse quickly assesses the
client's vital signs and notes that the pulse rate has increased and that the blood
pressure has dropped. The nurse determines that the client is most likely experiencing
which sign? - ✔✔Air embolism
✔✔A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of
tightness at the IV insertion site. On data collection, the nurse detects coolness and
swelling at the site and notes that the IV rate has slowed. The nurse determines that
which has occurred? - ✔✔Infiltration
, ✔✔One unit of packed red blood cells is infusing into a client over a 4-hour period. The
unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse
determines that the flow rate should be set at how many drops per minute? Fill in the
blank and round answer to the nearest whole number.10 - ✔✔16
✔✔The nurse is performing a vaginal check of a pregnant client in labor. The nurse
notes that the umbilical cord is protruding from the vagina. Which action should the
nurse immediately perform? - ✔✔Exert upward pressure against the presenting part
with gloved fingers.
✔✔A client in the postpartum unit complains of sudden, sharp chest pain. The client is
tachycardic and the respiratory rate is increased, and the primary health care provider
diagnoses a pulmonary embolism. Which interventions apply to the care of this client?
Select all that apply. - ✔✔Administer oxygen.
Monitor the blood pressure.
Prepare to administer morphine sulfate.
Prepare to start an intravenous (IV) line.
✔✔The nurse is checking the date of an intravenous (IV) insertion in a client. The
insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site
should be changed on which date? - ✔✔2/12
✔✔The nurse is reinforcing instructions regarding cardiopulmonary resuscitation (CPR)
to a group of nursing students. The nurse tells the group that when performing chest
compressions on adults, the sternum should be depressed to at least which depth? -
✔✔2 inches
✔✔A child is admitted to the burn unit with partial- and full-thickness burns over 35% of
the body. The nurse assisting in caring for the child develops the plan of care. Which
nursing intervention is the priority? - ✔✔Inserting a Foley catheter
✔✔A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the
child should prepare to assist in administering which medication? - ✔✔Dimercaprol
✔✔The emergency department nurse is caring for a child brought to the emergency
department following the ingestion of approximately one half bottle of acetylsalicylic acid
(aspirin) 10 minutes before arrival. Which should the nurse anticipate as the likely initial
treatment? - ✔✔The administration of activated charcoal
✔✔The nurse is assisting in preparing to administer acetylcysteine to a client with an
overdose of acetaminophen. How should the nurse administer the medication? - ✔✔Mix
the medication in a flavored ice drink, and allow the client to drink the medication
through a straw.
QUESTIONS WITH ANSWERS GRADED A+
✔✔The nursing student is asked to describe the correct steps for performing adult
cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of
priority. All options must be used. - ✔✔Initiate breathing
Open the client's airway.
Determine unconsciousness by shaking the client and asking, "Are you OK?"
Perform chest compressions.
✔✔A client presents to the emergency department with upper gastrointestinal (GI)
bleeding and is in moderate distress. Which nursing action should be the priority for this
client? - ✔✔Determine vital signs.
✔✔The nurse is assisting in monitoring the condition of a client after pericardiocentesis
for cardiac tamponade. Which observation indicates that the procedure was
unsuccessful? - ✔✔Distant and muffled heart sounds
✔✔A client is receiving thrombolytic therapy by continuous infusion. The client suddenly
becomes extremely anxious and complains of itching. The nurse hears stridor, and on
examination of the client, notes generalized urticaria and hypotension. Which should be
the priority action of the nurse? - ✔✔Stop the infusion, and notify the registered nurse.
✔✔A family of a spinal cord-injured client rushes to the nursing station, saying that the
client needs immediate help. On entering the room, the nurse notes that the client is
diaphoretic, with a flushed face and neck, and complains of a severe headache. The
pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts
quickly, knowing that the client is experiencing which condition? - ✔✔Autonomic
dysreflexia
✔✔A client who has been receiving total parenteral nutrition by way of a central venous
access device complains of chest pain and dyspnea. The nurse quickly assesses the
client's vital signs and notes that the pulse rate has increased and that the blood
pressure has dropped. The nurse determines that the client is most likely experiencing
which sign? - ✔✔Air embolism
✔✔A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of
tightness at the IV insertion site. On data collection, the nurse detects coolness and
swelling at the site and notes that the IV rate has slowed. The nurse determines that
which has occurred? - ✔✔Infiltration
, ✔✔One unit of packed red blood cells is infusing into a client over a 4-hour period. The
unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse
determines that the flow rate should be set at how many drops per minute? Fill in the
blank and round answer to the nearest whole number.10 - ✔✔16
✔✔The nurse is performing a vaginal check of a pregnant client in labor. The nurse
notes that the umbilical cord is protruding from the vagina. Which action should the
nurse immediately perform? - ✔✔Exert upward pressure against the presenting part
with gloved fingers.
✔✔A client in the postpartum unit complains of sudden, sharp chest pain. The client is
tachycardic and the respiratory rate is increased, and the primary health care provider
diagnoses a pulmonary embolism. Which interventions apply to the care of this client?
Select all that apply. - ✔✔Administer oxygen.
Monitor the blood pressure.
Prepare to administer morphine sulfate.
Prepare to start an intravenous (IV) line.
✔✔The nurse is checking the date of an intravenous (IV) insertion in a client. The
insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site
should be changed on which date? - ✔✔2/12
✔✔The nurse is reinforcing instructions regarding cardiopulmonary resuscitation (CPR)
to a group of nursing students. The nurse tells the group that when performing chest
compressions on adults, the sternum should be depressed to at least which depth? -
✔✔2 inches
✔✔A child is admitted to the burn unit with partial- and full-thickness burns over 35% of
the body. The nurse assisting in caring for the child develops the plan of care. Which
nursing intervention is the priority? - ✔✔Inserting a Foley catheter
✔✔A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the
child should prepare to assist in administering which medication? - ✔✔Dimercaprol
✔✔The emergency department nurse is caring for a child brought to the emergency
department following the ingestion of approximately one half bottle of acetylsalicylic acid
(aspirin) 10 minutes before arrival. Which should the nurse anticipate as the likely initial
treatment? - ✔✔The administration of activated charcoal
✔✔The nurse is assisting in preparing to administer acetylcysteine to a client with an
overdose of acetaminophen. How should the nurse administer the medication? - ✔✔Mix
the medication in a flavored ice drink, and allow the client to drink the medication
through a straw.
