1. Which of the following is the priority action when caring for a
patient who is exhibiting signs of hypoglycemia?
A) Administer insulin
B) Check the blood glucose level
C) Provide a snack with protein and carbs
D) Assess for signs of hyperglycemia
Answer: B) Check the blood glucose level
Rationale: The priority action for a patient showing signs of
hypoglycemia (such as confusion, tremors, or weakness) is to first check
the blood glucose level. This confirms whether the patient is
hypoglycemic or not, and further interventions can be planned based
on that information. Giving insulin or assessing for hyperglycemia is not
appropriate for a suspected hypoglycemic episode.
2. A nurse is educating a patient about the importance of taking a
prescribed antibiotic. Which statement made by the patient indicates
the need for further education?
A) "I will take the medication until I feel better."
B) "I will take the full course of antibiotics as prescribed."
C) "I will take the medication at the same time each day."
D) "I will not stop taking the medication even if I feel better."
Answer: A) "I will take the medication until I feel better."
Rationale: The patient should be educated on the importance of
completing the entire course of antibiotics, even if they begin to feel
better. Stopping the medication early can lead to antibiotic resistance
and a potential recurrence of the infection.
,3. When assessing a patient’s pulse, which of the following is the most
accurate method for determining the rate?
A) Count the number of beats for 30 seconds and multiply by 2
B) Count the number of beats for 15 seconds and multiply by 4
C) Count the number of beats for 1 minute
D) Palpate the pulse for 5 seconds and note the rate
Answer: C) Count the number of beats for 1 minute
Rationale: The most accurate method for determining a patient's pulse
rate is to count the beats for a full minute. This ensures the most
precise measurement, especially when the pulse is irregular. Multiplying
shorter counts (e.g., 15 or 30 seconds) is only a reliable method when
the pulse is regular.
4. A nurse is caring for a patient who has been prescribed furosemide
(Lasix). The nurse knows that which of the following lab results should
be closely monitored during therapy?
A) Serum potassium
B) Serum calcium
C) Serum sodium
D) Serum glucose
Answer: A) Serum potassium
Rationale: Furosemide is a diuretic that can cause potassium loss,
leading to hypokalemia. Therefore, serum potassium levels should be
closely monitored to prevent complications such as cardiac arrhythmias.
, 5. A nurse is assisting a patient with post-operative pain management.
Which of the following is the best intervention for a patient who rates
their pain as 6/10 on the pain scale?
A) Administer the prescribed pain medication as ordered
B) Encourage the patient to use deep breathing techniques
C) Offer the patient a warm compress
D) Ask the patient to rate their pain again in 30 minutes
Answer: A) Administer the prescribed pain medication as ordered
Rationale: When a patient reports moderate pain (6/10), the best
intervention is to administer prescribed pain medication. Non-
pharmacological interventions, such as deep breathing or warm
compresses, may also be used, but pharmacological pain management
is the priority for moderate pain.
6. When caring for a patient with a central venous catheter (CVC),
which action is most important to prevent infection?
A) Use a sterile technique when changing the dressing
B) Flush the catheter with saline once a day
C) Ensure the catheter is flushed with heparin every shift
D) Perform a blood culture before administering antibiotics
Answer: A) Use a sterile technique when changing the dressing
Rationale: The most important action to prevent infection is to use
sterile technique when changing the dressing over the central venous
catheter (CVC). This reduces the risk of introducing pathogens into the
bloodstream.
patient who is exhibiting signs of hypoglycemia?
A) Administer insulin
B) Check the blood glucose level
C) Provide a snack with protein and carbs
D) Assess for signs of hyperglycemia
Answer: B) Check the blood glucose level
Rationale: The priority action for a patient showing signs of
hypoglycemia (such as confusion, tremors, or weakness) is to first check
the blood glucose level. This confirms whether the patient is
hypoglycemic or not, and further interventions can be planned based
on that information. Giving insulin or assessing for hyperglycemia is not
appropriate for a suspected hypoglycemic episode.
2. A nurse is educating a patient about the importance of taking a
prescribed antibiotic. Which statement made by the patient indicates
the need for further education?
A) "I will take the medication until I feel better."
B) "I will take the full course of antibiotics as prescribed."
C) "I will take the medication at the same time each day."
D) "I will not stop taking the medication even if I feel better."
Answer: A) "I will take the medication until I feel better."
Rationale: The patient should be educated on the importance of
completing the entire course of antibiotics, even if they begin to feel
better. Stopping the medication early can lead to antibiotic resistance
and a potential recurrence of the infection.
,3. When assessing a patient’s pulse, which of the following is the most
accurate method for determining the rate?
A) Count the number of beats for 30 seconds and multiply by 2
B) Count the number of beats for 15 seconds and multiply by 4
C) Count the number of beats for 1 minute
D) Palpate the pulse for 5 seconds and note the rate
Answer: C) Count the number of beats for 1 minute
Rationale: The most accurate method for determining a patient's pulse
rate is to count the beats for a full minute. This ensures the most
precise measurement, especially when the pulse is irregular. Multiplying
shorter counts (e.g., 15 or 30 seconds) is only a reliable method when
the pulse is regular.
4. A nurse is caring for a patient who has been prescribed furosemide
(Lasix). The nurse knows that which of the following lab results should
be closely monitored during therapy?
A) Serum potassium
B) Serum calcium
C) Serum sodium
D) Serum glucose
Answer: A) Serum potassium
Rationale: Furosemide is a diuretic that can cause potassium loss,
leading to hypokalemia. Therefore, serum potassium levels should be
closely monitored to prevent complications such as cardiac arrhythmias.
, 5. A nurse is assisting a patient with post-operative pain management.
Which of the following is the best intervention for a patient who rates
their pain as 6/10 on the pain scale?
A) Administer the prescribed pain medication as ordered
B) Encourage the patient to use deep breathing techniques
C) Offer the patient a warm compress
D) Ask the patient to rate their pain again in 30 minutes
Answer: A) Administer the prescribed pain medication as ordered
Rationale: When a patient reports moderate pain (6/10), the best
intervention is to administer prescribed pain medication. Non-
pharmacological interventions, such as deep breathing or warm
compresses, may also be used, but pharmacological pain management
is the priority for moderate pain.
6. When caring for a patient with a central venous catheter (CVC),
which action is most important to prevent infection?
A) Use a sterile technique when changing the dressing
B) Flush the catheter with saline once a day
C) Ensure the catheter is flushed with heparin every shift
D) Perform a blood culture before administering antibiotics
Answer: A) Use a sterile technique when changing the dressing
Rationale: The most important action to prevent infection is to use
sterile technique when changing the dressing over the central venous
catheter (CVC). This reduces the risk of introducing pathogens into the
bloodstream.
