1. A postoperative patient has a blood pressure of 88/58 mmHg, heart
rate of 122 bpm, and cold, clammy skin. What is the nurse’s priority?
A. Administer a prescribed vasopressor.
B. Start a fluid bolus as prescribed.
C. Notify the healthcare provider.
D. Monitor urine output.
Answer and Rationale:
B. Start a fluid bolus as prescribed.
Rationale: These are signs of hypovolemic shock, and fluid resuscitation
is the first-line treatment.
2. 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.
,3. 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.
4. A patient with an ischemic stroke is receiving thrombolytic therapy.
Which finding requires immediate intervention?
A. Headache
B. Blood pressure of 180/100 mmHg
C. New-onset confusion
D. Blood glucose of 150 mg/dL
Answer and Rationale:
C. New-onset confusion
Rationale: This may indicate intracranial hemorrhage, a life-
threatening complication of thrombolytic therapy.
, 5. A progressive care nurse is caring for a patient with sepsis. Which
finding indicates the need for immediate intervention?
A. Blood pressure 90/60 mmHg
B. Heart rate 112 bpm
C. Lactate level 4 mmol/L
D. Temperature 38.5°C (101.3°F)
Answer and Rationale:
C. Lactate level 4 mmol/L
Rationale: A lactate level >2 mmol/L indicates tissue hypoperfusion
and possible organ dysfunction. Prompt interventions are needed to
address underlying sepsis.
6. A patient with a history of heart failure reports palpitations and
dizziness. The ECG shows frequent premature ventricular contractions
(PVCs). What is the nurse’s priority?
A. Administer an antiarrhythmic as prescribed.
B. Assess potassium and magnesium levels.
C. Notify the healthcare provider.
D. Monitor the frequency of PVCs.
Answer and Rationale:
B. Assess potassium and magnesium levels.
Rationale: Electrolyte imbalances often cause PVCs, so addressing
these imbalances is essential.
rate of 122 bpm, and cold, clammy skin. What is the nurse’s priority?
A. Administer a prescribed vasopressor.
B. Start a fluid bolus as prescribed.
C. Notify the healthcare provider.
D. Monitor urine output.
Answer and Rationale:
B. Start a fluid bolus as prescribed.
Rationale: These are signs of hypovolemic shock, and fluid resuscitation
is the first-line treatment.
2. 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.
,3. 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.
4. A patient with an ischemic stroke is receiving thrombolytic therapy.
Which finding requires immediate intervention?
A. Headache
B. Blood pressure of 180/100 mmHg
C. New-onset confusion
D. Blood glucose of 150 mg/dL
Answer and Rationale:
C. New-onset confusion
Rationale: This may indicate intracranial hemorrhage, a life-
threatening complication of thrombolytic therapy.
, 5. A progressive care nurse is caring for a patient with sepsis. Which
finding indicates the need for immediate intervention?
A. Blood pressure 90/60 mmHg
B. Heart rate 112 bpm
C. Lactate level 4 mmol/L
D. Temperature 38.5°C (101.3°F)
Answer and Rationale:
C. Lactate level 4 mmol/L
Rationale: A lactate level >2 mmol/L indicates tissue hypoperfusion
and possible organ dysfunction. Prompt interventions are needed to
address underlying sepsis.
6. A patient with a history of heart failure reports palpitations and
dizziness. The ECG shows frequent premature ventricular contractions
(PVCs). What is the nurse’s priority?
A. Administer an antiarrhythmic as prescribed.
B. Assess potassium and magnesium levels.
C. Notify the healthcare provider.
D. Monitor the frequency of PVCs.
Answer and Rationale:
B. Assess potassium and magnesium levels.
Rationale: Electrolyte imbalances often cause PVCs, so addressing
these imbalances is essential.
