Question: A client reports sudden, severe chest pain rated 9/10 that radiates to the left arm. The nurse notes diaphoresis and shortness of breath. What is the priority action?
Options:
A. Administer prescribed nitroglycerin.
B. Notify the healthcare provider immediately.
C. Obtain a 12-lead ECG.
D. Provide reassurance and stay with the client.
Click to reveal answer
Answer: C. Obtain a 12-lead ECG.
Explanation:
The client’s symptoms suggest acute myocardial infarction (MI). The priority is to obtain an ECG within 10 minutes to confirm ischemia or infarction, per ACS (acute coronary syndrome) protocols. While nitroglycerin (A) and notifying the provider (B) are important, diagnosis must occur first. Staying with the client (D) is supportive but not the priority.
2. Which Client Should the Nurse Assess First?
Question: The nurse receives report on four clients. Which client requires immediate assessment?
Options:
A. A post-op client with a pain score of 6/10.
B. A diabetic client with a blood glucose of 250 mg/dL.
C. A COPD client with an SpO₂ of 88% on 2L NC.
D. A heart failure client with 2+ pedal edema.
Click to reveal answer
Answer: C. A COPD client with an SpO₂ of 88% on 2L NC.
Explanation:
An SpO₂ of 88% indicates hypoxia, which is life-threatening and requires prompt intervention (e.g., oxygen titration). Pain (A) and hyperglycemia (B) are urgent but not immediate threats. Pedal edema (D) is chronic and less urgent.
3. Prioritizing Care for a Client with a Head Injury
Question: A client with a head injury has a Glasgow Coma Scale (GCS) score of 10, slurred speech, and unilateral pupil dilation. What is the priority nursing action?
Options:
A. Elevate the head of the bed.
B. Administer IV mannitol.
C. Prepare for emergency intubation.
D. Assess vital signs every 15 minutes.
Click to reveal answer
Answer: A. Elevate the head of the bed.
Explanation:
Unilateral pupil dilation suggests increased intracranial pressure (ICP). Elevating the head (A) promotes venous drainage to reduce ICP. Mannitol (B) may be ordered but is not the nurse’s first action. Intubation (C) may be needed but requires a provider order. Vital signs (D) are important but secondary to reducing ICP.
4. Immediate Intervention for a Postpartum Hemorrhage
Question: A postpartum client has saturated a perineal pad in 15 minutes and has a BP of 85/50 mmHg. What is the priority intervention?
Options:
A. Massage the uterine fundus.
B. Administer IV oxytocin.
C. Increase IV fluid rate.
D. Notify the provider.
Click to reveal answer
Answer: A. Massage the uterine fundus.
Explanation:
The client shows signs of postpartum hemorrhage due to uterine atony. Fundal massage (A) is the first-line action to stimulate uterine contraction. Oxytocin (B) and fluids (C) follow. Notification (D) is critical but does not replace immediate intervention.
5. Which Client is at Highest Risk for Suicide?
Question: The nurse reviews four clients’ charts. Which client is the highest priority for suicide risk?
Options:
A. A client with a history of depression who states, “I’m fine now.”
B. A client who recently lost a spouse and says, “I can’t go on.”
C. A client with schizophrenia who reports auditory hallucinations.
D. A client with a suicide plan, means (pills), and intent.
Click to reveal answer
Answer: D. A client with a suicide plan, means (pills), and intent.
Explanation:
The highest risk is a client with a specific plan, means, and intent (D). Recent loss (B) and hallucinations (C) are concerning but less urgent without a plan. Denial (A) may mask risk but is less acute.