1
Page | 1
Concepts for Nursing Practice (4th
Edition) by Jean Giddens
, 2
Q1. A nurse is caring for a patient with type 2 diabetes who is prescribed metformin. Which
Page | 2 lab result requires immediate follow-up?
a. Hemoglobin A1c: 6.8%
b. BUN: 22 mg/dL
c. Creatinine: 2.1 mg/dL ✅✅✅
d. Potassium: 4.6 mEq/L
Answer: C
Rationale: Metformin is contraindicated in renal impairment. Creatinine >1.5 mg/dL (men)
or >1.4 mg/dL (women) increases risk of lactic acidosis.
DIF: Analyze
TOP: Medication Safety
MSC: NCLEX: Physiological Integrity
Q2. A nurse assesses a client postoperatively and notes sudden shortness of breath, low
oxygen saturation, and chest pain. Which priority action reflects the nurse’s use of clinical
judgment?
a. Administering PRN acetaminophen
b. Documenting findings and notifying housekeeping
c. Applying oxygen and notifying the provider ✅✅✅
d. Elevating the head of bed and reassessing later
, 3
Answer: C
Rationale: These symptoms may indicate a pulmonary embolism. Oxygen and immediate
provider contact reflect critical clinical judgment.
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DIF: Analyze
TOP: Clinical Judgment
MSC: NCLEX: Physiological Integrity
Q3. A nurse is preparing to administer a medication that requires two nurse verifications.
Which concept is most directly applied?
a. Teamwork & Collaboration
b. Quality Improvement
c. Safety ✅✅✅
d. Evidence-Based Practice
Answer: C
Rationale: Double-checking high-risk medications is a key safety strategy that reduces
medication errors.
DIF: Understand
TOP: Safety
MSC: NCLEX: Safe and Effective Care Environment
Q4. A patient receiving IV potassium reports a burning sensation at the IV site. What is the
nurse’s best initial action?
, 4
a. Increase the IV rate
b. Stop the infusion immediately
c. Apply ice to the site
Page | 4
d. Check the IV site for infiltration ✅✅✅
Answer: D
Rationale: Potassium is a vesicant; infiltration can cause tissue damage. First assess the IV
site before acting.
DIF: Apply
TOP: Clinical Judgment
MSC: NCLEX: Physiological Integrity
Q5. A nurse notes that a newly admitted patient has a pressure injury on the sacrum. What is
the priority nursing action?
a. Notify the physician immediately
b. Document the finding and stage the injury ✅✅✅
c. Apply antibiotic ointment
d. Delegate wound care to unlicensed personnel
Answer: B
Rationale: Documentation and staging ensure appropriate care and protect against liability
related to pre-existing conditions.
DIF: Apply
TOP: Safety
MSC: NCLEX: Health Promotion and Maintenance
Page | 1
Concepts for Nursing Practice (4th
Edition) by Jean Giddens
, 2
Q1. A nurse is caring for a patient with type 2 diabetes who is prescribed metformin. Which
Page | 2 lab result requires immediate follow-up?
a. Hemoglobin A1c: 6.8%
b. BUN: 22 mg/dL
c. Creatinine: 2.1 mg/dL ✅✅✅
d. Potassium: 4.6 mEq/L
Answer: C
Rationale: Metformin is contraindicated in renal impairment. Creatinine >1.5 mg/dL (men)
or >1.4 mg/dL (women) increases risk of lactic acidosis.
DIF: Analyze
TOP: Medication Safety
MSC: NCLEX: Physiological Integrity
Q2. A nurse assesses a client postoperatively and notes sudden shortness of breath, low
oxygen saturation, and chest pain. Which priority action reflects the nurse’s use of clinical
judgment?
a. Administering PRN acetaminophen
b. Documenting findings and notifying housekeeping
c. Applying oxygen and notifying the provider ✅✅✅
d. Elevating the head of bed and reassessing later
, 3
Answer: C
Rationale: These symptoms may indicate a pulmonary embolism. Oxygen and immediate
provider contact reflect critical clinical judgment.
Page | 3
DIF: Analyze
TOP: Clinical Judgment
MSC: NCLEX: Physiological Integrity
Q3. A nurse is preparing to administer a medication that requires two nurse verifications.
Which concept is most directly applied?
a. Teamwork & Collaboration
b. Quality Improvement
c. Safety ✅✅✅
d. Evidence-Based Practice
Answer: C
Rationale: Double-checking high-risk medications is a key safety strategy that reduces
medication errors.
DIF: Understand
TOP: Safety
MSC: NCLEX: Safe and Effective Care Environment
Q4. A patient receiving IV potassium reports a burning sensation at the IV site. What is the
nurse’s best initial action?
, 4
a. Increase the IV rate
b. Stop the infusion immediately
c. Apply ice to the site
Page | 4
d. Check the IV site for infiltration ✅✅✅
Answer: D
Rationale: Potassium is a vesicant; infiltration can cause tissue damage. First assess the IV
site before acting.
DIF: Apply
TOP: Clinical Judgment
MSC: NCLEX: Physiological Integrity
Q5. A nurse notes that a newly admitted patient has a pressure injury on the sacrum. What is
the priority nursing action?
a. Notify the physician immediately
b. Document the finding and stage the injury ✅✅✅
c. Apply antibiotic ointment
d. Delegate wound care to unlicensed personnel
Answer: B
Rationale: Documentation and staging ensure appropriate care and protect against liability
related to pre-existing conditions.
DIF: Apply
TOP: Safety
MSC: NCLEX: Health Promotion and Maintenance
