(2025_2026
1. A patient with type 2 diabetes has a fasting glucose of 180 mg/dL. Which is the priority
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nursing action?
A. Administer prescribed insulin
B. Encourage oral intake
C. Monitor vitals only
D. Restrict fluids
Answer: A. Administer prescribed insulin
Rationale: Hyperglycemia requires prompt treatment to prevent complications like DKA or
hyperosmolar hyperglycemic state.
2. A patient with asthma presents with wheezing and shortness of breath. Which
✅
intervention is priority?
A. Administer short-acting bronchodilator
B. Encourage oral fluids
C. Provide high-protein diet
D. Monitor bowel sounds
Answer: A. Administer short-acting bronchodilator
Rationale: Bronchodilators relieve airway obstruction and improve oxygenation immediately.
3. A patient with heart failure develops pulmonary edema. Which is the priority
✅
intervention?
A. Administer prescribed diuretics
B. Encourage oral fluids
C. Elevate legs only
D. Monitor temperature
Answer: A. Administer prescribed diuretics
Rationale: Diuretics reduce fluid overload and improve oxygenation.
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4. Which lab result indicates hypokalemia?
A. K⁺ 2.8 mEq/L
B. Na⁺ 140 mEq/L
C. Ca²⁺ 9.0 mg/dL
D. Cl⁻ 100 mEq/L
Answer: A. K⁺ 2.8 mEq/L
Rationale: Normal potassium is 3.5–5.0 mEq/L. Hypokalemia increases risk for arrhythmias
and muscle weakness.
5. A patient with hyperkalemia (K⁺ 6.5 mEq/L) shows peaked T waves on ECG. Which is
✅
the priority intervention?
A. Administer calcium gluconate
B. Restrict oral fluids
C. Monitor vitals only
D. Encourage high-potassium foods
Answer: A. Administer calcium gluconate
Rationale: Calcium stabilizes cardiac membranes and prevents life-threatening arrhythmias.
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6. A patient with COPD is experiencing dyspnea. Which position is best?
A. High Fowler’s
B. Supine
C. Trendelenburg
D. Left lateral
Answer: A. High Fowler’s
Rationale: Upright positioning improves diaphragmatic movement and oxygenation.
7. A patient with DKA has fruity breath and Kussmaul respirations. Priority nursing
✅
action?
A. Administer IV fluids and insulin
B. Encourage oral fluids
C. Monitor vitals only
D. Restrict activity
,Answer: A. Administer IV fluids and insulin
Rationale: Fluids correct dehydration, and insulin lowers blood glucose and ketones,
preventing complications.
8. A patient with hypoglycemia is diaphoretic and confused. Which is the first
✅
intervention?
A. Administer 15 g of fast-acting carbohydrate
B. Encourage oral fluids
C. Monitor temperature
D. Restrict protein
Answer: A. Administer 15 g of fast-acting carbohydrate
Rationale: Early hypoglycemia requires rapid glucose replacement to prevent seizures or loss
of consciousness.
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9. A patient on warfarin has an INR of 4.5. Which is priority?
A. Hold warfarin and notify provider
B. Continue as prescribed
C. Increase dose
D. Monitor daily
Answer: A. Hold warfarin and notify provider
Rationale: INR above therapeutic range increases bleeding risk; dose adjustment or reversal
may be needed.
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10. Which intervention prevents DVT in a postoperative patient?
A. Encourage early ambulation and leg exercises
B. Massage calves
C. Restrict fluids
D. Apply tight bandages
Answer: A. Encourage early ambulation and leg exercises
Rationale: Early mobilization and leg exercises promote venous return and reduce clot risk.
11. A patient with suspected anaphylaxis has facial swelling and dyspnea. Priority
✅
action?
A. Assess airway and prepare for emergency intervention
B. Administer antihistamines only
, C. Notify family
D. Document findings
Answer: A. Assess airway and prepare for emergency intervention
Rationale: Airway compromise is life-threatening; epinephrine and emergency support are
critical.
12. A patient with hyponatremia (Na⁺ 125 mEq/L) is confused. Which intervention is
✅
priority?
A. Administer hypertonic IV fluids as prescribed
B. Encourage oral fluids
C. Restrict fluids
D. Monitor vitals only
Answer: A. Administer hypertonic IV fluids as prescribed
Rationale: Severe hyponatremia with neurological symptoms requires careful correction to
prevent seizures and brain injury.
13. A patient with suspected sepsis has hypotension and tachycardia. Which intervention
✅
is priority?
A. Administer IV fluids and notify provider
B. Monitor temperature
C. Encourage bed rest
D. Restrict oral intake
Answer: A. Administer IV fluids and notify provider
Rationale: Early aggressive fluid resuscitation restores perfusion and prevents organ failure.
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14. A patient with COPD has increased sputum production and fever. Priority action?
A. Obtain sputum culture and administer antibiotics as prescribed
B. Encourage oral fluids
C. Place in supine position
D. Provide high-protein diet
Answer: A. Obtain sputum culture and administer antibiotics as prescribed
Rationale: Fever and increased sputum indicate possible infection requiring prompt treatment.