1. A patient has a central venous catheter and reports sudden shortness
of breath. The nurse notices decreased oxygen saturation and
hypotension. What is the priority intervention?
A. Administer a prescribed diuretic.
B. Position the patient on their left side with the head down.
C. Notify the healthcare provider immediately.
D. Remove the central venous catheter.
Answer and Rationale:
B. Position the patient on their left side with the head down.
Rationale: This position traps air in the right atrium, minimizing the
risk of air embolism traveling to the lungs or brain.
2. A patient recovering from a myocardial infarction reports new-onset
chest discomfort radiating to the jaw. What is the nurse's first action?
A. Administer nitroglycerin sublingually.
B. Perform a 12-lead ECG.
C. Obtain vital signs.
D. Notify the healthcare provider.
Answer and Rationale:
B. Perform a 12-lead ECG.
,Rationale: A 12-lead ECG is critical to determine if the chest
discomfort is due to ischemia or a recurrent myocardial infarction. This
guides subsequent interventions.
3. The nurse is caring for a patient with a chest tube following thoracic
surgery. Which observation requires immediate action?
A. 50 mL of drainage in the last hour.
B. Continuous bubbling in the water seal chamber.
C. Tidaling in the water seal chamber during inspiration.
D. The chest tube is secured to the chest wall.
Answer and Rationale:
B. Continuous bubbling in the water seal chamber.
Rationale: Continuous bubbling indicates an air leak, which requires
immediate assessment and intervention.
4. A patient on a progressive care unit reports sudden severe headache
and vomiting. Blood pressure is 200/120 mmHg. What is the nurse’s
priority?
A. Perform a neurological assessment.
B. Notify the healthcare provider immediately.
C. Administer an IV antihypertensive as prescribed.
D. Place the patient in a semi-Fowler’s position.
Answer and Rationale:
, C. Administer an IV antihypertensive as prescribed.
Rationale: This presentation suggests a hypertensive crisis, which
requires immediate blood pressure reduction.
5. A patient develops asystole on the monitor. What is the nurse’s
priority action?
A. Start chest compressions immediately.
B. Administer epinephrine IV as prescribed.
C. Prepare for defibrillation.
D. Notify the healthcare provider.
Answer and Rationale:
A. Start chest compressions immediately.
Rationale: Asystole is a non-shockable rhythm, and immediate CPR is
essential to restore circulation.
6. A patient with end-stage renal disease reports severe itching. What
intervention is most appropriate?
A. Administer prescribed antihistamines.
B. Encourage increased water intake.
C. Monitor phosphorus levels.
D. Apply emollients to the skin.
Answer and Rationale:
C. Monitor phosphorus levels.
of breath. The nurse notices decreased oxygen saturation and
hypotension. What is the priority intervention?
A. Administer a prescribed diuretic.
B. Position the patient on their left side with the head down.
C. Notify the healthcare provider immediately.
D. Remove the central venous catheter.
Answer and Rationale:
B. Position the patient on their left side with the head down.
Rationale: This position traps air in the right atrium, minimizing the
risk of air embolism traveling to the lungs or brain.
2. A patient recovering from a myocardial infarction reports new-onset
chest discomfort radiating to the jaw. What is the nurse's first action?
A. Administer nitroglycerin sublingually.
B. Perform a 12-lead ECG.
C. Obtain vital signs.
D. Notify the healthcare provider.
Answer and Rationale:
B. Perform a 12-lead ECG.
,Rationale: A 12-lead ECG is critical to determine if the chest
discomfort is due to ischemia or a recurrent myocardial infarction. This
guides subsequent interventions.
3. The nurse is caring for a patient with a chest tube following thoracic
surgery. Which observation requires immediate action?
A. 50 mL of drainage in the last hour.
B. Continuous bubbling in the water seal chamber.
C. Tidaling in the water seal chamber during inspiration.
D. The chest tube is secured to the chest wall.
Answer and Rationale:
B. Continuous bubbling in the water seal chamber.
Rationale: Continuous bubbling indicates an air leak, which requires
immediate assessment and intervention.
4. A patient on a progressive care unit reports sudden severe headache
and vomiting. Blood pressure is 200/120 mmHg. What is the nurse’s
priority?
A. Perform a neurological assessment.
B. Notify the healthcare provider immediately.
C. Administer an IV antihypertensive as prescribed.
D. Place the patient in a semi-Fowler’s position.
Answer and Rationale:
, C. Administer an IV antihypertensive as prescribed.
Rationale: This presentation suggests a hypertensive crisis, which
requires immediate blood pressure reduction.
5. A patient develops asystole on the monitor. What is the nurse’s
priority action?
A. Start chest compressions immediately.
B. Administer epinephrine IV as prescribed.
C. Prepare for defibrillation.
D. Notify the healthcare provider.
Answer and Rationale:
A. Start chest compressions immediately.
Rationale: Asystole is a non-shockable rhythm, and immediate CPR is
essential to restore circulation.
6. A patient with end-stage renal disease reports severe itching. What
intervention is most appropriate?
A. Administer prescribed antihistamines.
B. Encourage increased water intake.
C. Monitor phosphorus levels.
D. Apply emollients to the skin.
Answer and Rationale:
C. Monitor phosphorus levels.
