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MULTIPLE CHOICES
1. A nurse assesses a client with heart failure who has crackles in both lung bases and an SpO2 of 89% on room
air. Which action should be taken first?
A. Place client in high-Fowler’s position
B. Administer furosemide IV push
C. Apply oxygen via nasal cannula
D. Notify the provider
Answer: C
Applying oxygen corrects hypoxemia first; positioning and diuretics follow, but hypoxia is the priority.
2. A client post-op day 1 from abdominal surgery reports sudden chest pain and dyspnea. Vital signs: HR 118, RR
32, BP 100/70. What is the priority?
A. Administer morphine sulfate
B. Obtain a STAT chest X-ray
C. Assess for lower extremity swelling
D. Initiate anticoagulation
Answer: B
Chest X-ray helps rule out pulmonary embolism or pneumonia; morphine treats pain but not the diagnostic
need.
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,3. A nurse is caring for a client on a heparin drip for DVT. The aPTT is 110 seconds (control 30). Which action is
correct?
A. Increase the drip rate
B. Stop the infusion and prepare protamine
C. Continue infusion and recheck in 6 hours
D. Decrease rate by 2 mL/hr
Answer: B
aPTT >100 seconds indicates excessive anticoagulation; protamine reverses heparin, and the infusion must be
stopped.
4. A client with schizophrenia tells the nurse, “They put cameras in my toothbrush to watch me.” Which
response is therapeutic?
A. “That sounds frightening. Tell me more about the cameras.”
B. “No one is watching you; that’s not real.”
C. “I don’t see any cameras. Let’s talk about something else.”
D. “Why would they put cameras in your toothbrush?”
Answer: A
Acknowledging the feeling without reinforcing delusion builds trust; challenging or analyzing content is
nontherapeutic.
5. A primigravida at 38 weeks reports a gush of fluid and then trickling. The nurse notes green-tinged fluid. What
is the priority?
A. Assess fetal heart rate
B. Check cervical dilation
C. Prepare for immediate delivery
D. Administer oxygen to mother
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,Answer: A
Green fluid indicates meconium; immediate fetal assessment for distress is priority before other interventions.
6. A nurse in a long-term care facility finds a resident on the floor next to the bed. The resident says, “I tried to
get up and fell.” What should the nurse do first?
A. Call the provider
B. Complete an incident report
C. Assess the resident for injuries
D. Help the resident back to bed
Answer: C
Assessment of airway, breathing, and injuries comes before any documentation or moving the client.
7. A child with newly diagnosed type 1 diabetes has a blood glucose of 55 mg/dL and is lethargic. Which
intervention is most appropriate?
A. Give 15 g rapid-acting carbohydrate
B. Administer glucagon subcutaneously
C. Offer 4 oz orange juice
D. Recheck blood glucose in 15 minutes
Answer: B
Lethargy suggests severe hypoglycemia where oral intake is unsafe; IM/subQ glucagon is needed.
8. A nurse is preparing to administer digoxin to a client with heart failure. The apical pulse is 52 bpm. What
should the nurse do?
A. Give the digoxin as ordered
B. Hold the dose and reassess in 1 hour
C. Hold the dose and notify the provider
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, D. Give half the dose and recheck rhythm
Answer: C
Digoxin is held for HR <60 in adults; provider notification is required because bradycardia may indicate toxicity.
9. A client prescribed warfarin has an INR of 1.2. The nurse expects which order?
A. Increase warfarin dose
B. Administer vitamin K
C. Hold warfarin for 2 days
D. Add enoxaparin
Answer: A
INR 1.2 is subtherapeutic (goal 2-3 for most); dose increase is typical; vitamin K lowers INR further.
10. A postpartum client reports a large, red, painful area on her calf. What is the priority?
A. Apply warm compresses
B. Massage the area gently
C. Measure the leg circumference
D. Immobilize the leg and notify provider
Answer: D
Suspect DVT; immobilization prevents embolization; massage could dislodge clot, so avoid.
11. During a code blue, the nurse notes the defibrillator shows ventricular fibrillation. What is the first action?
A. Administer epinephrine
B. Perform CPR for 2 minutes
C. Defibrillate immediately
D. Insert an advanced airway
Page 4 of 89 SUCCESS!!!