Answers & Detailed Rationales | Latest Update
1. Priority
A client with chest pain, diaphoresis, and nausea arrives in the ER. What is the priority
action?
A. Obtain ECG
B. Give antacid
C. Take full history
D. Encourage rest
✔ Answer: A
Rationale: Suspected MI → ECG first to confirm ischemia.
2. Airway
Which client is at highest risk for airway obstruction?
A. Asthma with wheezing
B. Stable COPD
C. Pneumonia with productive cough
D. Mild flu
✔ Answer: A
Wheezing indicates narrowed airway → immediate risk.
3. Hypoglycemia
Which symptom is expected?
A. Fruity breath
B. Sweating and tremors
C. Deep breathing
D. Dry skin
,✔ Answer: B
Sympathetic activation = sweating, shaking.
4. Infection control
Which requires airborne precautions?
A. TB
B. MRSA
C. Influenza
D. Hepatitis B
✔ Answer: A
5. Delegation
Which task can be given to UAP?
A. Assess pain
B. Give insulin
C. Assist with feeding
D. Evaluate wound
✔ Answer: C
6. Post-op complication
Sudden shortness of breath after surgery suggests:
A. Infection
B. Pulmonary embolism
C. Anxiety
D. Hypoglycemia
✔ Answer: B
7. Medication safety
Before giving digoxin, nurse should check:
, A. Blood glucose
B. Heart rate
C. Temperature
D. Oxygen level
✔ Answer: B
8. DKA
Which finding confirms DKA?
A. Low glucose
B. Fruity breath
C. Bradycardia
D. Fluid overload
✔ Answer: B
9. Shock
Early sign of shock:
A. Hypotension
B. Tachycardia
C. Cyanosis
D. Organ failure
✔ Answer: B
10. Stroke
FAST acronym includes:
A. Fever
B. Arm weakness
C. Abdominal pain
D. Chest pain
✔ Answer: B