,Section A — Fundamentals and Clinical Judgment
Q1. A postoperative patient reports sudden chest pain and shortness of breath
two hours after surgery; which action is highest priority?
A. Administer PRN opioid for pain
B. Assess airway, breathing, and oxygen saturation immediately
C. Notify the surgeon for immediate return to OR
D. Encourage deep breathing and coughing exercises
Airway and breathing assessment is highest priority for sudden cardiopulmonary
symptoms.
Q2. A nurse finds a confused older adult wandering the unit at night; which
intervention best reduces fall risk immediately?
A. Apply physical restraints without assessment
B. Perform a fall risk assessment and implement bed alarm and frequent
checks
C. Discharge the patient home early
D. Ignore behavior until morning rounds
,Immediate fall prevention measures and assessment reduce risk while planning
further care.
Q3. A patient with COPD has increased work of breathing and SpO₂ 88% on room
air; what is the nurse’s first action?
A. Start high-flow oxygen at 15 L/min via nonrebreather
B. Apply supplemental oxygen at appropriate flow and reassess
respiratory status
C. Administer a bronchodilator without assessment
D. Obtain a chest x-ray immediately
Supplemental oxygen and reassessment address hypoxia while further evaluation
proceeds.
Q4. A patient scheduled for discharge lacks transportation home; which nursing
action best supports safe discharge planning?
A. Send patient home regardless of transport
B. Coordinate social work or community resources to arrange safe
transport
C. Cancel discharge indefinitely without alternatives
, D. Discharge patient to emergency department
Arranging safe transport ensures continuity of care and patient safety at
discharge.
Q5. A nurse preparing to administer an IM injection should first verify which of
the following to ensure correct administration?
A. Patient’s favorite food preferences
B. Medication, dose, route, site, and patient identity per five rights
C. Nurse’s personal schedule only
D. Pharmacy inventory levels only
Verifying the five rights prevents medication errors and ensures safe
administration.
Q6. A patient with diabetes reports dizziness and sweating after insulin
administration; which action should the nurse take first?
A. Give a full meal immediately
B. Check blood glucose and provide fast-acting carbohydrate if
hypoglycemic
Q1. A postoperative patient reports sudden chest pain and shortness of breath
two hours after surgery; which action is highest priority?
A. Administer PRN opioid for pain
B. Assess airway, breathing, and oxygen saturation immediately
C. Notify the surgeon for immediate return to OR
D. Encourage deep breathing and coughing exercises
Airway and breathing assessment is highest priority for sudden cardiopulmonary
symptoms.
Q2. A nurse finds a confused older adult wandering the unit at night; which
intervention best reduces fall risk immediately?
A. Apply physical restraints without assessment
B. Perform a fall risk assessment and implement bed alarm and frequent
checks
C. Discharge the patient home early
D. Ignore behavior until morning rounds
,Immediate fall prevention measures and assessment reduce risk while planning
further care.
Q3. A patient with COPD has increased work of breathing and SpO₂ 88% on room
air; what is the nurse’s first action?
A. Start high-flow oxygen at 15 L/min via nonrebreather
B. Apply supplemental oxygen at appropriate flow and reassess
respiratory status
C. Administer a bronchodilator without assessment
D. Obtain a chest x-ray immediately
Supplemental oxygen and reassessment address hypoxia while further evaluation
proceeds.
Q4. A patient scheduled for discharge lacks transportation home; which nursing
action best supports safe discharge planning?
A. Send patient home regardless of transport
B. Coordinate social work or community resources to arrange safe
transport
C. Cancel discharge indefinitely without alternatives
, D. Discharge patient to emergency department
Arranging safe transport ensures continuity of care and patient safety at
discharge.
Q5. A nurse preparing to administer an IM injection should first verify which of
the following to ensure correct administration?
A. Patient’s favorite food preferences
B. Medication, dose, route, site, and patient identity per five rights
C. Nurse’s personal schedule only
D. Pharmacy inventory levels only
Verifying the five rights prevents medication errors and ensures safe
administration.
Q6. A patient with diabetes reports dizziness and sweating after insulin
administration; which action should the nurse take first?
A. Give a full meal immediately
B. Check blood glucose and provide fast-acting carbohydrate if
hypoglycemic
