Day 3 -

1. A 69-year-old male patient with a history of liver cirrhosis is admitted to the hospital with complaints of confusion, lethargy, and weakness. Laboratory results reveal serum sodium of 124 mEq/L. Which of the following is the most appropriate nursing intervention?

A. Encourage increased oral free water intake to correct the hyponatremia.

B. Restrict fluid intake as prescribed and monitor neurological status.

C. Administer a hypotonic IV solution to rapidly correct sodium level.

D. Place the patient in a Trendelenburg position to improve cerebral perfusion.

A 69-year-old male arrives at the emergency department complaining of generalized body malaise. His ECG shows supraventricular tachycardia (SVT) with a heart rate of 180 bpm. The physician orders adenosine 6 mg IV push. Which action should the nurse take when administering this medication?

A. Administer the medication slowly over 2 minutes followed by a saline flush.

B. Administer the medication rapidly over 1-2 seconds followed by a rapid saline flush.

C. Administer the medication intramuscularly in the deltoid followed by observation.

D. Administer the medication via infusion pump over 15 minutes to minimize side effects.

3. A 56-year-old female patient is in the ICU receiving an insulin drip for the management of hyperglycemia. Which of the following is the most important nursing action to prevent complications related to insulin therapy?

A. Monitor the patient’s urine output every hour.

B. Check the patient’s blood glucose levels hourly.

C. Assess the patient’s blood pressure every 4 hours.

D. Observe the patient’s IV site for signs of infiltration.

4. A 65-year-old male patient in the medical ward is noted to have a recurrence of supraventricular tachycardia (SVT) with a heart rate of 180 bpm. The patient is alert, oriented, and reports palpitations and dizziness. What is the nurse’s priority initial action?

A. Prepare the patient for synchronized cardioversion.

B. Instruct the patient to perform the Valsalva maneuver.

C. Administer adenosine 6 mg IV push as ordered.

D. Apply oxygen at 2 L/min via nasal cannula.

5. A 76-year-old male patient in the ICU is receiving an insulin drip for the management of diabetic ketoacidosis. The nurse notes that the patient’s serum potassium level has decreased from 4.2 mEq/L to 3.2 mEq/L. What is the priority nursing action?

A. Continue the insulin drip and recheck potassium levels in 4 hours.

B. Stop the insulin drip immediately.

C. Notify the healthcare provider and prepare to administer potassium supplementation as ordered.

D. Administer a dose of calcium gluconate to protect the heart.

6. A nurse is caring for a client who is scheduled for surgery. Which of the following actions demonstrates the nurse’s role as a client advocate?

A. Witnessing the client’s signature on the consent form.

B. Explaining the surgical procedure to the client.

C. Verifying that the client understands the procedure and consents voluntarily.

D. Informing the client’s family of the surgical risks.

7. To reduce the risk of transmitting infections between clients and healthcare workers, which of the following actions should the nurse take to effectively prevent the spread of infection?

A. Use alcohol-based hand rub after removing gloves.

B. Wash hands with soap and water for 10 seconds.

C. Reuse gloves for the same patient.

D. Wear gloves when entering any client’s room.

8. A 50-year-old adult client comes to the clinic for a routine check-up and expresses interest in learning about recommended health screenings appropriate for their age. As the nurse provides patient education, which of the following screenings should the nurse prioritize recommending based on current preventive health guidelines for this age group?

A. Papanicolaou (Pap) smear for cervical cancer.

B. Colonoscopy for colorectal cancer.

C. Prostate-specific antigen (PSA) blood test.

D. Newborn hearing screening test.

9. An 81-year-old male is brought to the emergency department with acute chest pain and a brief loss of consciousness. The patient has a history of hypertension and type 2 diabetes mellitus. On admission, vital signs are: BP 88/56 mmHg, HR 42 bpm, RR 20/min, SpO₂ 94% on room air. An ECG shows ST-segment elevation in the inferior leads. The nurse recognizes that the patient is experiencing acute coronary syndrome (ACS) with likely inferior myocardial infarction.

Which of the following actions should the nurse take first?

A. Administer sublingual nitroglycerin.

B. Obtain a 12-lead ECG.

C. Initiate IV access and prepare for atropine administration.

D. Place the patient in a high Fowler’s position.

10. A nurse is caring for a client recently diagnosed with terminal cancer. The client states, “I feel like this is a mistake.” Which stage of grief is the client exhibiting?

A. Denial.

B. Anger.

C. Bargaining.

D. Depression.

11. A 66-year-old female client is 12 hours postoperative following an open cholecystectomy. She reports abdominal discomfort. Which action should the nurse take first?

A. Notify the provider.

B. Offer pain medication.

C. Encourage the client to ambulate.

D. Assess the client’s abdomen.

12. A nurse is preparing to administer digoxin to a 48-year-old male patient in the Cardiac Care Unit. During assessment, the nurse notes that the patient’s apical heart rate is 52 beats per minute. What is the most appropriate nursing intervention?

A. Administer the medication as prescribed and document the heart rate.

B. Hold the medication and notify the healthcare provider.

C. Give the medication with a full glass of water to prevent nausea.

D. Recheck the apical heart rate in 15 minutes and proceed if it increases.

13.

A child is brought to the emergency department after sustaining a bite from an animal confirmed to be rabid. What is the nurse’s priority action?

A. Clean the wound thoroughly with soap and water.

B. Administer tetanus toxoid vaccine.

C. Prepare the child for surgical wound debridement.

D. Apply a sterile dressing to the bite wound.

14. A post-operative client in the Surgical Unit is receiving intravenous potassium chloride (KCl) in a maintenance IV fluid order. Which of the following findings requires immediate nursing intervention?

A. The client reports mild incisional pain rated 4/10.

B. The client has a serum potassium level of 3.8 mEq/L.

C. The IV site is warm, red, and tender to the touch.

D. The client’s urine output is 50 mL/hour.

15. A nurse is caring for a client with extensive full-thickness burns over 40% of the body. The client is showing signs of hypovolemic shock. Which intervention is the priority?

A. Apply oxygen.

B. Monitor urinary output.

C. Obtain a blood specimen.

D. Administer antihypertensives.

16. A nurse in the Emergency Room is caring for a client who is confused, has a respiratory rate of 32/min, appears restless, and has a pulse of 88/min. Which assessment finding is the most concerning cue requiring immediate intervention?

A. Confusion.

B. Respiratory rate of 32/min.

C. Restlessness.

D. Pulse of 88/min.

17. A client in the Emergency Department with a history of laryngeal cancer suddenly becomes dyspneic, is using accessory muscles to breathe, and has stridor. The nurse suspects the client’s airway is being blocked by the tumor. What is the priority nursing action?

A. Encourage the client to keep coughing.

B. Prepare for emergency tracheostomy.

C. Administer a bronchodilator.

D. Obtain a chest X-ray.

18. A nurse finds a client with a tracheostomy tube who is coughing forcefully and appears unable to speak. What is the nurse’s priority action?

A. Encourage the client to keep coughing.

B. Perform abdominal thrusts.

C. Suction the tracheostomy.

D. Call the rapid response team.

19. A nurse on a medical-surgical unit is delegating tasks to a licensed practical nurse (LPN). Which of the following tasks is appropriate for the LPN to perform?

A. Developing a care plan.

B. Administering IV push medications.

C. Performing wound irrigation.

D. Assessing postoperative pain.

20. A nurse in a rehabilitation unit delegates the ambulation of a stable client to an unlicensed assistive personnel (UAP). What is the nurse’s primary responsibility before delegation?

A. Document the ambulation.

B. Supervise the UAP directly.

C. Assess the client’s ability to ambulate.

D. Explain the reason for ambulation.

21. A nurse in a medical-surgical unit receives the change-of-shift report. Which client should the nurse assess first?

A. A postoperative client complaining of nausea.

B. A client with a blood glucose of 50 mg/dL.

C. A client with a potassium level of 3.5 mEq/L.

D. A client who received pain medication 30 minutes ago.

22. A nurse in the intensive care unit (ICU) is reviewing client data. Which client finding requires the nurse to notify the healthcare provider immediately?

A. Blood pressure of 138/86 mmHg.

B. Sodium level of 132 mEq/L.

C. Urine output of 20 mL/hr.

D. Hemoglobin level of 13 g/dL.

Correct Answer: B. Prepare for emergency tracheostomy