1. A nurse is caring for a patient with a history of diabetes mellitus who
is experiencing hypoglycemia. Which of the following should the nurse
administer first?
A. 15 grams of carbohydrates
B. Insulin
C. Glucagon
D. A protein snack
Answer: a) 15 grams of carbohydrates
Rationale: In hypoglycemia, the first step is to administer 15 grams of a
fast-acting carbohydrate, such as glucose tablets or juice, to rapidly
increase blood glucose levels.
2. A nurse is caring for a patient diagnosed with pneumonia. Which of
the following is the most appropriate nursing intervention?
A. Administer prescribed antibiotics as soon as possible
B. Encourage the patient to lie flat to aid in lung expansion
C. Administer oxygen only if the patient’s oxygen saturation falls
below 90%
D. Restrict the patient’s fluid intake to prevent further infection
Answer: a) Administer prescribed antibiotics as soon as possible
,Rationale: Early antibiotic treatment is essential in pneumonia to
combat the infection and reduce the risk of complications.
3. A nurse is administering a dose of morphine sulfate to a patient in
severe pain. What is the most important monitoring parameter for this
patient?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Oxygen saturation
Answer: c) Respiratory rate
Rationale: Morphine, like other opioids, can depress the respiratory
system, leading to respiratory depression. Monitoring the respiratory
rate is crucial to detect early signs of respiratory compromise.
4. A nurse is caring for a patient receiving chemotherapy. Which of the
following interventions is most important to minimize the risk of
infection?
A. Encourage frequent handwashing
B. Offer a high-fiber diet
C. Administer prophylactic antibiotics
D. Ensure the patient gets adequate rest
Answer: a) Encourage frequent handwashing
, Rationale: Chemotherapy suppresses the immune system, making
patients more susceptible to infections. Frequent handwashing is one of
the most effective measures to prevent infection.
5. A nurse is caring for a postoperative patient who is experiencing
pain. The patient requests medication, stating their pain is a "10" on a
scale of 0-10. The nurse's first action should be to:
A. Administer the prescribed pain medication
B. Ask the patient to describe the pain further
C. Assess the patient's vital signs
D. Notify the physician about the patient's pain
Answer: c) Assess the patient's vital signs
Rationale: Before administering pain medication, the nurse should first
assess vital signs to rule out any complications, such as hypotension or
tachycardia, which may be linked to pain or other postoperative
concerns.
6. A nurse is caring for a patient who has been prescribed digoxin for
heart failure. Which of the following is the most important assessment
before administering the medication?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Oxygen saturation
is experiencing hypoglycemia. Which of the following should the nurse
administer first?
A. 15 grams of carbohydrates
B. Insulin
C. Glucagon
D. A protein snack
Answer: a) 15 grams of carbohydrates
Rationale: In hypoglycemia, the first step is to administer 15 grams of a
fast-acting carbohydrate, such as glucose tablets or juice, to rapidly
increase blood glucose levels.
2. A nurse is caring for a patient diagnosed with pneumonia. Which of
the following is the most appropriate nursing intervention?
A. Administer prescribed antibiotics as soon as possible
B. Encourage the patient to lie flat to aid in lung expansion
C. Administer oxygen only if the patient’s oxygen saturation falls
below 90%
D. Restrict the patient’s fluid intake to prevent further infection
Answer: a) Administer prescribed antibiotics as soon as possible
,Rationale: Early antibiotic treatment is essential in pneumonia to
combat the infection and reduce the risk of complications.
3. A nurse is administering a dose of morphine sulfate to a patient in
severe pain. What is the most important monitoring parameter for this
patient?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Oxygen saturation
Answer: c) Respiratory rate
Rationale: Morphine, like other opioids, can depress the respiratory
system, leading to respiratory depression. Monitoring the respiratory
rate is crucial to detect early signs of respiratory compromise.
4. A nurse is caring for a patient receiving chemotherapy. Which of the
following interventions is most important to minimize the risk of
infection?
A. Encourage frequent handwashing
B. Offer a high-fiber diet
C. Administer prophylactic antibiotics
D. Ensure the patient gets adequate rest
Answer: a) Encourage frequent handwashing
, Rationale: Chemotherapy suppresses the immune system, making
patients more susceptible to infections. Frequent handwashing is one of
the most effective measures to prevent infection.
5. A nurse is caring for a postoperative patient who is experiencing
pain. The patient requests medication, stating their pain is a "10" on a
scale of 0-10. The nurse's first action should be to:
A. Administer the prescribed pain medication
B. Ask the patient to describe the pain further
C. Assess the patient's vital signs
D. Notify the physician about the patient's pain
Answer: c) Assess the patient's vital signs
Rationale: Before administering pain medication, the nurse should first
assess vital signs to rule out any complications, such as hypotension or
tachycardia, which may be linked to pain or other postoperative
concerns.
6. A nurse is caring for a patient who has been prescribed digoxin for
heart failure. Which of the following is the most important assessment
before administering the medication?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Oxygen saturation
