1.
A 68-year-old male patient is admitted with a diagnosis of congestive heart failure (CHF). He is receiving IV furosemide 40 mg twice a day. On the second day of treatment, he reports generalized muscle weakness and leg cramps. His vital signs are: BP 100/62 mmHg, HR 98 bpm, RR 20, SpO₂ 96%. Lab results reveal serum potassium of 2.8 mmol/L. What is the most appropriate initial nursing intervention?
2.
A 24-year-old woman in her third trimester presents to the emergency department with upper right quadrant pain, blurred vision, and a BP of 165/105 mmHg. She has a history of gestational hypertension but is not on any antihypertensive therapy. Urinalysis shows +3 proteinuria. What is the nurse's priority action at this point?
3.
A 10-year-old child is admitted for acute appendicitis. While awaiting surgery, the child begins vomiting, has a temperature of 39.4°C, HR of 130, and severe abdominal pain that suddenly disappears. The child now lies still and is guarding his abdomen. What is the most appropriate nursing action?
4.
A 76-year-old patient with dementia is admitted for pneumonia. He is confused, keeps pulling at his IV line, and tries to get out of bed. The nurse has tried reorientation and distraction techniques with little success. What is the next best nursing intervention?
5.
A nurse is caring for a 5-year-old child with nephrotic syndrome who has gained 3 kg in the last 48 hours and has periorbital and lower limb edema. Urine output is reduced, and the child is lethargic. Which of the following should be the priority nursing assessment?
6.
A 52-year-old woman receiving chemotherapy for breast cancer reports tingling and numbness in her hands and feet. She says she is finding it hard to button her shirt or walk in a straight line. What should the nurse do first?
7.
A nurse is caring for a patient 24 hours post-op from abdominal surgery. The patient has a fever of 38.5°C, a heart rate of 105, and complains of pain at the surgical site. The nurse notes redness, warmth, and purulent drainage from the incision. What is the nurse's priority intervention?
8.
A 3-day-old newborn is brought to the emergency department with poor feeding, lethargy, and a temperature of 35.5°C. The baby is limp, pale, and has a weak cry. What should the nurse do first?
9.
During a night shift, a nurse enters the room and finds an elderly patient with a tracheostomy tube showing signs of respiratory distress. The patient is using accessory muscles and oxygen saturation has dropped to 84%. What is the first nursing action?
10.
A nurse is preparing a patient for discharge following treatment for heart failure. The patient asks if it’s okay to have canned soup for lunch. Which response by the nurse is most appropriate?
11.
A 2-year-old child is admitted with severe dehydration due to acute gastroenteritis. The child is lethargic, has sunken eyes, and a heart rate of 160 bpm. The parents report that the child has had diarrhea for the past three days, with minimal oral intake. Question: What is the priority nursing intervention for this child?
12.
A 45-year-old male patient with a history of schizophrenia presents to the emergency department exhibiting agitation, rapid speech, and decreased need for sleep. He has not been taking his antipsychotic medication regularly. Question: What is the most appropriate initial nursing action?
13.
A 60-year-old female patient is admitted to the ICU post-cardiac surgery. She is intubated and on mechanical ventilation. Arterial blood gases (ABG) reveal a pH of 7.32, PaCO₂ of 50 mmHg, and PaO₂ of 80 mmHg. Question: What is the priority nursing intervention?
14.
A 28-year-old pregnant woman at 32 weeks gestation presents with complaints of severe headaches, visual disturbances, and swelling of the hands and face. Her blood pressure is 160/110 mmHg, and urine dipstick shows 2+ proteinuria. Question: What is the most likely diagnosis, and what is the priority nursing action?
15.
A 58-year-old male is admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). He is on 2L/min oxygen via nasal cannula. His respiratory rate is 32/min, he is using accessory muscles, and his oxygen saturation is 89%. What is the nurse’s priority action?
16.
You are teaching a new graduate nurse about the correct technique for taking blood pressure. The nurse places the cuff over a patient’s sleeve and immediately inflates it. What is the correct response?
17.
A postpartum woman who delivered vaginally 1 hour ago has saturated two perineal pads in 20 minutes. Her fundus is boggy and deviated to the right side. What is the nurse’s first action?
18.
A nurse is caring for a 4-year-old child hospitalized for asthma. The child suddenly becomes irritable and refuses to lie down, and you hear decreased breath sounds.
19.
A patient with major depressive disorder tells the nurse, “I’ve been thinking about how everything would be better if I just disappeared.” What is the nurse’s best response?
20.
A patient in ICU post-surgery suddenly becomes restless, short of breath, and reports chest pain. His oxygen saturation drops to 86%, and he is tachycardic. What is the most likely cause, and what should you do first?
21.
A patient scheduled for surgery tells the nurse he no longer wishes to proceed. The surgeon has already explained the procedure and obtained a signed consent. What is the nurse’s best action?
22.
During a home visit, a nurse finds a toddler crawling near exposed electrical wires and cleaning chemicals on the floor. What is the nurse’s priority intervention?
23.
A patient with Clostridium difficile (C. diff) infection requires isolation precautions. A new nurse enters the room with gloves and a surgical mask but no gown. What is the correct nursing response?
24.
While reviewing medication orders, a nurse finds two drugs with similar names: hydroxyzine and hydralazine. One is for anxiety, and the other for hypertension. What is the best nursing action?
25.
You are the charge nurse on a busy medical-surgical floor with four staff members: one RN (you), one newly licensed RN, one LPN, and one unlicensed assistive personnel (UAP). You are receiving a new admission from the ER: a 74-year-old with suspected pneumonia, shortness of breath, and a history of COPD. Which task is most appropriate to delegate to the UAP while you admit the new patient?
