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1. A 68-year-old patient with heart failure is admitted with worsening dyspnea, bilateral
crackles, and +3 pitting edema. Which intervention should the nurse prioritize?
A. Encourage increased oral fluids
B. Administer prescribed diuretics
C. Place patient in Trendelenburg position
D. Restrict oxygen therapy
Answer: B
Rationale: Diuretics reduce fluid overload, which is the primary cause of pulmonary
congestion and edema in heart failure. This improves oxygenation and decreases
cardiac workload. Oxygen should be administered if needed, not restricted.
2. A post-operative patient suddenly reports chest pain and shortness of breath. What is
the nurse’s first action?
A. Administer analgesics
B. Check oxygen saturation
C. Notify the provider
D. Encourage deep breathing
Answer: B
Rationale: The nurse must first assess oxygenation status to determine severity. Post-
operative chest pain with dyspnea may indicate pulmonary embolism, requiring
immediate evaluation.
, 3. A diabetic patient is confused, sweaty, and trembling. Blood glucose is 48 mg/dL.
What is the priority intervention?
A. Administer IV insulin
B. Give 15g fast-acting carbohydrates
C. Restrict oral intake
D. Prepare for dialysis
Answer: B
Rationale: The patient is experiencing hypoglycemia. Rapid glucose replacement is
essential to prevent neurological damage.
4. A patient with pneumonia has a respiratory rate of 30/min and oxygen saturation of
88%. What should the nurse do first?
A. Encourage oral fluids
B. Apply oxygen therapy
C. Obtain sputum culture
D. Position supine
Answer: B
Rationale: Oxygen therapy is the priority to correct hypoxia before other interventions.
5. A client receiving morphine develops respiratory depression. What is the nurse’s
priority action?
A. Administer naloxone
B. Increase IV fluids
C. Encourage coughing
D. Elevate lower extremities
Answer: A
Rationale: Naloxone reverses opioid-induced respiratory depression and is the antidote.