NCLEX Critical Thinking in Nursing Practice Exam
Which action is the highest priority when a nurse suspects a patient is at risk for aspiration?
Encouraging small, frequent meals
B. Thickening all oral fluids
C. Placing the patient in a high-Fowler’s position during meals
D. Assessing bowel sounds regularly
Answer: C. Placing the patient in a high-Fowler’s position during meals
A nurse is caring for a patient with pneumonia. Which assessment finding requires immediate intervention?
Temperature of 100.4°F (38°C)
B. Respiratory rate of 32 breaths/min
C. Oxygen saturation of 94% on room air
D. Cough producing yellow sputum
Answer: B. Respiratory rate of 32 breaths/min
A patient reports pain of 8/10 on a numeric scale. What is the nurse’s first action?
Administer prescribed analgesics immediately
B. Reassess the pain after 30 minutes
C. Assess the patient’s vital signs
D. Ask the patient to describe the pain further
Answer: D. Ask the patient to describe the pain further
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. The nurse’s priority is to:
Monitor oxygen saturation levels
B. Avoid oxygen rates above 2 L/min
C. Educate the patient about pursed-lip breathing
D. Increase the oxygen flow rate during activity
Answer: B. Avoid oxygen rates above 2 L/min
Which patient finding is most concerning to a nurse?
Blood pressure of 130/84 mmHg in a hypertensive patient
B. Heart rate of 120 bpm post-exercise
C. Urine output of 15 mL/hr for the past 2 hours
D. Blood glucose of 140 mg/dL after lunch
Answer: C. Urine output of 15 mL/hr for the past 2 hours
What is the best way to verify placement of a nasogastric tube?
Inject air and listen for a whooshing sound
B. Check the pH of aspirated contents
C. Ask the patient if they feel the tube in their stomach
D. Monitor for bowel sounds
Answer: B. Check the pH of aspirated contents
A nurse is preparing to administer digoxin. The patient’s apical pulse is 58 bpm. What should the nurse do?
Administer the medication as ordered
B. Hold the medication and notify the provider
C. Double-check the dosage with another nurse
D. Reassess the pulse in 30 minutes
Answer: B. Hold the medication and notify the provider
A patient with diabetes presents with confusion and diaphoresis. What is the nurse’s first action?
Check the patient’s blood glucose level
B. Administer 1 ampule of D50 IV
C. Reassess vital signs in 15 minutes
D. Notify the healthcare provider immediately
Answer: A. Check the patient’s blood glucose level
During shift handoff, a nurse reports that a patient has a stage II pressure ulcer. Which finding supports this classification?
Intact skin with non-blanchable redness
B. Open wound with partial-thickness skin loss
C. Deep crater with exposed muscle
D. Black eschar covering the wound
Answer: B. Open wound with partial-thickness skin loss
A patient on warfarin therapy has an INR of 5.0. The nurse should:
Administer the next dose of warfarin
B. Prepare to administer vitamin K
C. Encourage the patient to eat leafy greens
D. Notify the healthcare provider and document
Answer: B. Prepare to administer vitamin K
A patient with heart failure is prescribed furosemide. Which finding would indicate the medication is effective?
Weight gain of 2 pounds overnight
B. Reduction in peripheral edema
C. Blood pressure of 160/90 mmHg
D. Heart rate of 120 bpm
Answer: B. Reduction in peripheral edema
A nurse is preparing to administer insulin. The patient’s blood glucose is 68 mg/dL. What should the nurse do first?
Administer the insulin as ordered
B. Give the patient a snack and recheck glucose
C. Hold the insulin and notify the provider
D. Document the blood glucose level
Answer: B. Give the patient a snack and recheck glucose
A patient in the emergency department presents with chest pain. What is the nurse’s priority action?
Notify the healthcare provider
B. Administer prescribed nitroglycerin
C. Obtain a 12-lead ECG
D. Assess the patient’s pain scale
Answer: C. Obtain a 12-lead ECG
Which task can the nurse delegate to a licensed practical nurse (LPN)?
Initial assessment of a newly admitted patient
B. Administering oral medications to a stable patient
C. Evaluating a patient’s response to treatment
D. Educating a patient about wound care
Answer: B. Administering oral medications to a stable patient
A nurse is caring for a patient with a chest tube. Which finding requires immediate intervention?
50 mL of drainage in the past hour
B. Continuous bubbling in the water seal chamber
C. Chest tube dressing is intact
D. Patient reports mild discomfort at the insertion site
Answer: B. Continuous bubbling in the water seal chamber
A patient on a heparin infusion reports severe back pain. The nurse should:
Reassure the patient this is a normal side effect
B. Stop the infusion and notify the healthcare provider
C. Increase the infusion rate to manage the pain
D. Administer prescribed pain medication
Answer: B. Stop the infusion and notify the healthcare provider
Which dietary selection is most appropriate for a patient with chronic kidney disease?
Baked chicken with mashed potatoes and green beans
B. Grilled salmon with brown rice and spinach
C. Cheeseburger with fries and a milkshake
D. Hot dog with chips and soda
Answer: A. Baked chicken with mashed potatoes and green beans
A patient is scheduled for a colonoscopy. The nurse should include which instruction in pre-procedure teaching?
Avoid solid foods for 24 hours before the procedure
B. Take all prescribed medications on the day of the procedure
C. Drink only clear liquids the morning of the procedure
D. Expect severe abdominal pain during the procedure
Answer: A. Avoid solid foods for 24 hours before the procedure
A nurse is administering medications via a feeding tube. Which action ensures safe administration?
Mix all medications together before administration
B. Flush the tube with water before and after each medication
C. Administer medications in liquid form only
D. Check for bowel sounds after administering medications
Answer: B. Flush the tube with water before and after each medication
A patient receiving blood transfusion develops chills, fever, and low back pain. What should the nurse do first?
Stop the transfusion immediately
B. Slow the transfusion rate
C. Notify the healthcare provider
D. Document the reaction in the patient’s chart
Answer: A. Stop the transfusion immediately
A patient with a spinal cord injury at T6 exhibits flushing and a pounding headache. What is the nurse’s first action?
Notify the healthcare provider immediately
B. Elevate the head of the bed to 90 degrees
C. Assess the patient’s bladder for distention
D. Administer prescribed antihypertensives
Answer: B. Elevate the head of the bed to 90 degrees
A nurse is providing discharge teaching for a patient on warfarin therapy. Which statement indicates a need for further teaching?
“I should avoid eating large amounts of spinach.”
B. “I need to have my INR checked regularly.”
C. “I can take ibuprofen for headaches.”
D. “I should use a soft toothbrush to avoid bleeding.”
Answer: C. “I can take ibuprofen for headaches.”
A patient with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the nurse’s priority?
Monitor for signs of dehydration
B. Check the patient’s blood glucose level
C. Educate the patient about dietary changes
D. Administer prescribed insulin
Answer: B. Check the patient’s blood glucose level
Which intervention is most appropriate for a patient experiencing acute alcohol withdrawal?
Administer prescribed benzodiazepines
B. Encourage the patient to drink fluids
C. Place the patient in restraints to prevent injury
D. Educate the patient about long-term rehabilitation
Answer: A. Administer prescribed benzodiazepines
A nurse notes a patient has a potassium level of 2.8 mEq/L. The priority assessment is:
Neurological status
B. Respiratory rate
C. Cardiac rhythm
D. Bowel sounds
Answer: C. Cardiac rhythm
A nurse is caring for a patient with a head injury. Which finding indicates increased intracranial pressure?
Bradycardia
B. Hypotension
C. Tachycardia
D. Hyperthermia
Answer: A. Bradycardia
Which patient is at highest risk for developing a pulmonary embolism?
A 25-year-old postpartum woman
B. A 60-year-old man who smokes
C. A 40-year-old woman on bed rest after surgery
D. A 50-year-old man with hypertension
Answer: C. A 40-year-old woman on bed rest after surgery
A patient with asthma has wheezing and diminished breath sounds. What should the nurse do first?
Administer prescribed bronchodilators
B. Place the patient on continuous oxygen
C. Notify the healthcare provider
D. Encourage the patient to cough and deep breathe
Answer: A. Administer prescribed bronchodilators
A nurse is caring for a patient with sepsis. Which finding is the most concerning?
Blood pressure of 86/52 mmHg
B. Heart rate of 96 bpm
C. Temperature of 101.3°F (38.5°C)
D. White blood cell count of 12,000/mm³
Answer: A. Blood pressure of 86/52 mmHg
A patient is receiving total parenteral nutrition (TPN). What is the nurse’s priority?
Monitoring daily weight
B. Checking blood glucose levels regularly
C. Measuring intake and output
D. Assessing bowel sounds
Answer: B. Checking blood glucose levels regularly
A nurse is teaching a patient about a newly prescribed metered-dose inhaler (MDI). Which instruction is correct?
“Exhale completely before placing the inhaler in your mouth.”
B. “Take quick, shallow breaths after releasing the medication.”
C. “Use the inhaler immediately after eating.”
D. “Shake the inhaler before each use.”
Answer: D. “Shake the inhaler before each use.”
A patient with a tracheostomy requires suctioning. What is the first step the nurse should take?
Apply suction while inserting the catheter
B. Hyperoxygenate the patient before suctioning
C. Suction for at least 30 seconds per pass
D. Secure the tracheostomy ties tightly
Answer: B. Hyperoxygenate the patient before suctioning
A nurse is caring for a postoperative patient. Which assessment finding requires immediate intervention?
A temperature of 99.5°F (37.5°C)
B. Sanguineous drainage on the dressing
C. A blood pressure of 90/50 mmHg
D. Pain rating of 6 on a scale of 0–10
Answer: C. A blood pressure of 90/50 mmHg
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which oxygen delivery device is most appropriate?
Non-rebreather mask at 10 L/min
B. Venturi mask at 2 L/min
C. Nasal cannula at 1-2 L/min
D. Simple face mask at 5 L/min
Answer: C. Nasal cannula at 1-2 L/min
A patient receiving a diuretic has a potassium level of 5.6 mEq/L. Which medication should the nurse anticipate administering?
Furosemide
B. Spironolactone
C. Potassium chloride
D. Calcium gluconate
Answer: A. Furosemide
A nurse is assessing a patient with suspected deep vein thrombosis (DVT). Which finding supports the diagnosis?
Positive Trousseau’s sign
B. Bilateral leg swelling
C. Calf pain and warmth
D. Cold, cyanotic extremity
Answer: C. Calf pain and warmth
A nurse is teaching a group of patients about hypertension management. Which statement indicates a need for further teaching?
“I will exercise for at least 30 minutes most days of the week.”
B. “I’ll take my blood pressure medication even when I feel fine.”
C. “I’ll eat canned soups since they’re quick and easy to prepare.”
D. “I’ll avoid adding salt to my meals.”
Answer: C. “I’ll eat canned soups since they’re quick and easy to prepare.”
A patient receiving chemotherapy reports nausea. What is the nurse’s best action?
Provide the patient with bland foods
B. Administer antiemetics as prescribed
C. Encourage the patient to lie flat
D. Restrict fluid intake during meals
Answer: B. Administer antiemetics as prescribed
Which laboratory finding is most concerning in a patient receiving warfarin therapy?
INR of 3.5
B. Platelet count of 150,000/mm³
C. Hemoglobin of 11 g/dL
D. INR of 5.2
Answer: D. INR of 5.2
The nurse is assessing a patient with pneumonia. Which finding suggests the condition is worsening?
Crackles in the lungs
B. Increased respiratory rate
C. Cyanosis of the lips
D. Productive cough
Answer: C. Cyanosis of the lips
A nurse is caring for a patient with hypothyroidism. Which symptom would the nurse expect?
Heat intolerance
B. Diarrhea
C. Bradycardia
D. Weight loss
Answer: C. Bradycardia
A patient on digoxin therapy reports nausea and vomiting. What is the nurse’s priority action?
Encourage the patient to eat small meals
B. Assess the patient’s digoxin level
C. Check the patient’s potassium level
D. Administer antiemetics as prescribed
Answer: B. Assess the patient’s digoxin level
A patient is receiving a blood transfusion and develops urticaria. What is the nurse’s priority action?
Stop the transfusion
B. Slow the transfusion rate
C. Notify the healthcare provider
D. Administer prescribed antihistamines
Answer: A. Stop the transfusion
Which patient is at highest risk for developing type 2 diabetes mellitus?
A 35-year-old male who exercises regularly
B. A 45-year-old female with a BMI of 32
C. A 30-year-old female with a history of anemia
D. A 40-year-old male with normal blood pressure
Answer: B. A 45-year-old female with a BMI of 32
A patient with cirrhosis has an elevated ammonia level. The nurse anticipates administering:
Lactulose
B. Furosemide
C. Metronidazole
D. Potassium chloride
Answer: A. Lactulose
A nurse is caring for a patient with a nasogastric tube. Which action ensures patency?
Administering crushed medications through the tube
B. Flushing the tube with water regularly
C. Clamping the tube when not in use
D. Keeping the patient in a supine position
Answer: B. Flushing the tube with water regularly
A patient with hyperkalemia is prescribed sodium polystyrene sulfonate. Which assessment is most important?
Heart rate
B. Bowel sounds
C. Respiratory rate
D. Urinary output
Answer: B. Bowel sounds
The nurse is teaching a patient about managing osteoporosis. Which statement indicates effective learning?
“I should avoid sunlight to protect my bones.”
B. “I’ll increase my intake of calcium-rich foods.”
C. “Weightlifting is not recommended for me.”
D. “I can continue smoking occasionally.”
Answer: B. “I’ll increase my intake of calcium-rich foods.”
Which intervention is most appropriate for a patient with left-sided heart failure?
Elevate the legs while the patient is sitting
B. Place the patient in a high Fowler’s position
C. Administer fluids at a rapid rate
D. Encourage bed rest and immobility
Answer: B. Place the patient in a high Fowler’s position
A nurse is reviewing the medication order for a patient with atrial fibrillation. Which medication should the nurse question?
Warfarin
B. Heparin
C. Aspirin
D. Atorvastatin
Answer: D. Atorvastatin
The nurse is monitoring a patient receiving IV potassium for hypokalemia. Which finding requires immediate intervention?
Serum potassium level of 4.0 mEq/L
B. Complaints of burning at the IV site
C. Urine output of 50 mL/hr
D. Cardiac monitor showing peaked T waves
Answer: D. Cardiac monitor showing peaked T waves
A nurse is caring for a patient with hyperthyroidism. Which symptom is most likely?
Bradycardia
B. Cold intolerance
C. Exophthalmos
D. Constipation
Answer: C. Exophthalmos
A patient with hypertension is prescribed a beta-blocker. Which side effect should the nurse teach the patient to report immediately?
Fatigue
B. Bradycardia
C. Dizziness
D. Dry mouth
Answer: B. Bradycardia
The nurse is teaching a diabetic patient about foot care. Which statement indicates a need for further teaching?
“I’ll use lotion to keep my feet soft, avoiding between my toes.”
B. “I’ll check my feet daily for cuts or sores.”
C. “I can go barefoot in my house if I’m careful.”
D. “I’ll trim my toenails straight across.”
Answer: C. “I can go barefoot in my house if I’m careful.”
A patient with pneumonia is receiving oxygen at 4 L/min via nasal cannula. The patient reports nasal dryness. What should the nurse do?
Switch to a non-rebreather mask
B. Increase the oxygen flow to 6 L/min
C. Add a humidifier to the oxygen setup
D. Encourage deep breathing exercises
Answer: C. Add a humidifier to the oxygen setup
A patient on long-term corticosteroid therapy develops moon face and buffalo hump. These findings are associated with:
Addison’s disease
B. Cushing’s syndrome
C. Hyperparathyroidism
D. Graves’ disease
Answer: B. Cushing’s syndrome
The nurse is assessing a patient post-thyroidectomy. Which finding requires immediate intervention?
Hoarseness
B. Tingling around the mouth
C. Sore throat
D. Difficulty swallowing
Answer: B. Tingling around the mouth
A nurse is preparing to administer an opioid analgesic. Which assessment is the highest priority?
Pain level
B. Respiratory rate
C. Level of consciousness
D. Blood pressure
Answer: B. Respiratory rate
A patient with heart failure is prescribed furosemide. Which lab value should the nurse monitor closely?
Sodium
B. Potassium
C. Hemoglobin
D. Magnesium
Answer: B. Potassium
A patient receiving heparin therapy has an aPTT of 90 seconds. What is the nurse’s priority action?
Document the findings as normal
B. Administer protamine sulfate
C. Increase the heparin infusion rate
D. Assess for signs of clot formation
Answer: B. Administer protamine sulfate
Which dietary choice is best for a patient with chronic kidney disease (CKD)?
Bananas and orange juice
B. Grilled chicken and white rice
C. Whole wheat bread and peanut butter
D. Baked potatoes and spinach
Answer: B. Grilled chicken and white rice
A patient receiving total parenteral nutrition (TPN) develops hyperglycemia. What is the nurse’s best action?
Slow the TPN infusion rate
B. Notify the healthcare provider
C. Check the TPN bag for lipids
D. Administer prescribed insulin
Answer: D. Administer prescribed insulin
A patient with chronic obstructive pulmonary disease (COPD) has a PaCO2 of 55 mmHg. What is the nurse’s interpretation?
Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
Answer: A. Respiratory acidosis
The nurse is caring for a patient receiving IV vancomycin. Which adverse reaction requires immediate intervention?
Nausea and vomiting
B. Redness and itching on the chest
C. Increased urine output
D. Elevated blood glucose
Answer: B. Redness and itching on the chest
A patient with a spinal cord injury develops a severe headache and high blood pressure. What is the nurse’s priority action?
Administer prescribed antihypertensives
B. Check for bladder distention
C. Elevate the head of the bed
D. Notify the healthcare provider
Answer: B. Check for bladder distention
A nurse is teaching a patient about warfarin therapy. Which statement indicates effective learning?
“I should avoid green leafy vegetables completely.”
B. “I need regular blood tests to monitor my INR.”
C. “I can take aspirin for headaches while on warfarin.”
D. “I should stop taking warfarin if I feel fine.”
Answer: B. “I need regular blood tests to monitor my INR.”
The nurse is caring for a patient with a chest tube. Which finding requires immediate intervention?
Continuous bubbling in the water seal chamber
B. Serous drainage in the collection chamber
C. Tidaling in the water seal chamber
D. Absence of drainage for one hour
Answer: A. Continuous bubbling in the water seal chamber
A patient with diabetes is experiencing hypoglycemia. What is the nurse’s best action?
Administer 1 mg of glucagon IM
B. Give the patient 4 oz of orange juice
C. Check the patient’s urine for ketones
D. Notify the healthcare provider immediately
Answer: B. Give the patient 4 oz of orange juice
A nurse is preparing to administer a blood transfusion. Which action reduces the risk of complications?
Warm the blood to room temperature before transfusion
B. Infuse the blood over 6 hours
C. Check patient identifiers with another nurse
D. Use a 24-gauge IV catheter
Answer: C. Check patient identifiers with another nurse
A patient with pancreatitis has a serum amylase level of 600 U/L. Which dietary intervention is most appropriate?
Encourage a high-fat diet
B. Start clear liquids as tolerated
C. Provide a high-protein, low-carb diet
D. Administer oral pancreatic enzymes with meals
Answer: B. Start clear liquids as tolerated
The nurse is assessing a patient with a new colostomy. Which statement indicates the patient needs additional teaching?
“I will clean around the stoma with mild soap and water.”
B. “I should change the pouch immediately if it begins to leak.”
C. “I’ll avoid high-fiber foods for the first 6 weeks.”
D. “I can expect the stoma to shrink significantly within 2 months.”
Answer: C. “I’ll avoid high-fiber foods for the first 6 weeks.”
A patient with liver cirrhosis is experiencing pruritus. What is the best nursing intervention?
Encourage frequent bathing with hot water
B. Apply lotion containing alcohol
C. Administer antihistamines as prescribed
D. Instruct the patient to eat a high-fat diet
Answer: C. Administer antihistamines as prescribed
The nurse is caring for a patient with septic shock. Which finding indicates the condition is worsening?
Warm, flushed skin
B. Blood pressure of 80/40 mmHg
C. Increased urinary output
D. Capillary refill of 2 seconds
Answer: B. Blood pressure of 80/40 mmHg
A patient recovering from a stroke has dysphagia. What action should the nurse take to prevent aspiration during meals?
Allow the patient to lie flat while eating
B. Offer thin liquids with a straw
C. Place the patient in a high Fowler’s position
D. Encourage large bites of food
Answer: C. Place the patient in a high Fowler’s position
A nurse is teaching a patient with osteoporosis about calcium supplementation. Which food is highest in calcium?
Apples
B. Almonds
C. Cheese
D. Rice
Answer: C. Cheese
A patient with a deep vein thrombosis is receiving heparin therapy. Which test will the nurse monitor to assess therapeutic effect?
PT/INR
B. aPTT
C. Platelet count
D. D-dimer
Answer: B. aPTT
A nurse is caring for a patient with suspected meningitis. What is the priority nursing intervention?
Administer prescribed antipyretics
B. Assess the patient’s level of consciousness
C. Initiate droplet precautions
D. Monitor for seizure activity
Answer: C. Initiate droplet precautions
A patient with chronic kidney disease has a potassium level of 6.2 mEq/L. What is the nurse’s first action?
Administer calcium gluconate as prescribed
B. Obtain a 12-lead ECG
C. Prepare the patient for dialysis
D. Restrict dietary potassium
Answer: A. Administer calcium gluconate as prescribed
The nurse is caring for a patient post-appendectomy. The patient reports severe abdominal pain with rigid muscles. What should the nurse do first?
Notify the healthcare provider
B. Administer prescribed pain medication
C. Check the patient’s vital signs
D. Encourage deep breathing exercises
Answer: A. Notify the healthcare provider
A nurse is providing discharge teaching to a patient prescribed digoxin. Which statement indicates understanding?
“I should take my pulse before taking the medication.”
B. “This medication might make my heart rate go faster.”
C. “I’ll avoid foods high in potassium.”
D. “I can stop taking the medication if I feel better.”
Answer: A. “I should take my pulse before taking the medication.”
A patient with diabetes is experiencing signs of diabetic ketoacidosis (DKA). Which laboratory result is most concerning?
Blood glucose of 320 mg/dL
B. pH of 7.25
C. Serum potassium of 5.0 mEq/L
D. Urine output of 50 mL/hr
Answer: B. pH of 7.25
A nurse is preparing to administer morning medications to a patient with dysphagia. Which intervention is best?
Crush all medications and mix with water
B. Administer medications with a small sip of water
C. Consult with the healthcare provider about alternative forms
D. Place the patient in a semi-Fowler’s position
Answer: C. Consult with the healthcare provider about alternative forms
A patient with asthma is experiencing wheezing and shortness of breath. Which medication should the nurse administer first?
Albuterol
B. Montelukast
C. Salmeterol
D. Fluticasone
Answer: A. Albuterol
The nurse is reviewing the discharge plan for a patient with heart failure. Which instruction is most important?
“Weigh yourself daily and report a gain of more than 2 pounds in 24 hours.”
B. “Take your diuretic only when you feel short of breath.”
C. “Avoid drinking more than 1 liter of fluids daily.”
D. “Limit exercise to reduce stress on your heart.”
Answer: A. “Weigh yourself daily and report a gain of more than 2 pounds in 24 hours.”
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which oxygen delivery device is most appropriate?
Non-rebreather mask
B. Venturi mask
C. Simple face mask
D. High-flow nasal cannula
Answer: B. Venturi mask
A patient with hypocalcemia has a positive Trousseau’s sign. Which additional finding is expected?
Lethargy
B. Muscle spasms
C. Bradycardia
D. Warm, flushed skin
Answer: B. Muscle spasms
A patient receiving chemotherapy is at risk for neutropenia. What is the nurse’s priority intervention?
Monitor for signs of infection
B. Encourage frequent handwashing
C. Provide a high-protein diet
D. Administer antiemetics as prescribed
Answer: A. Monitor for signs of infection
A nurse is caring for a patient post-splenectomy. Which complication is most concerning?
Fever
B. Nausea
C. Mild pain at the incision site
D. Slightly elevated white blood cell count
Answer: A. Fever
A patient with a urinary tract infection is prescribed phenazopyridine. What should the nurse teach the patient?
“This medication will treat the infection.”
B. “You may experience orange-colored urine.”
C. “Take this medication on an empty stomach.”
D. “Discontinue the medication if your symptoms improve.”
Answer: B. “You may experience orange-colored urine.”
The nurse is teaching a patient about the DASH diet. What is the primary goal of this diet?
Promote weight loss
B. Lower blood pressure
C. Reduce cholesterol levels
D. Manage diabetes
Answer: B. Lower blood pressure
A patient with Parkinson’s disease is experiencing difficulty swallowing. What is the nurse’s priority intervention?
Offer frequent snacks
B. Provide a liquid diet
C. Encourage chin-tuck swallowing technique
D. Administer prescribed anticholinergic medications
Answer: C. Encourage chin-tuck swallowing technique
The nurse is caring for a patient with a suspected pulmonary embolism. Which intervention should the nurse prioritize?
Encourage the patient to ambulate frequently
B. Administer oxygen therapy
C. Place the patient in the Trendelenburg position
D. Prepare the patient for a chest X-ray
Answer: B. Administer oxygen therapy
A patient reports severe pain after a total hip replacement. What is the nurse’s best initial action?
Notify the healthcare provider immediately
B. Reassess the pain level after 2 hours
C. Administer prescribed analgesics
D. Elevate the affected leg
Answer: C. Administer prescribed analgesics
A patient with heart failure is prescribed furosemide. Which lab value should the nurse monitor closely?
Hemoglobin
B. Potassium
C. Calcium
D. Creatinine
Answer: B. Potassium
The nurse is teaching a patient about insulin administration. Which statement by the patient indicates understanding?
“I will shake the vial of insulin before drawing it up.”
B. “I should inject insulin into the same site each time.”
C. “I will rotate injection sites to prevent tissue damage.”
D. “I need to keep the vial in the freezer.”
Answer: C. “I will rotate injection sites to prevent tissue damage.”
A patient with anemia reports fatigue and shortness of breath. What is the nurse’s priority intervention?
Encourage fluid intake
B. Promote frequent rest periods
C. Administer oxygen therapy
D. Recommend iron-rich foods
Answer: C. Administer oxygen therapy
The nurse is caring for a patient with bacterial pneumonia. Which finding requires immediate intervention?
Yellow sputum production
B. Oxygen saturation of 88%
C. Fever of 101°F (38.3°C)
D. Respiratory rate of 24 breaths/min
Answer: B. Oxygen saturation of 88%
A patient with diabetes is experiencing symptoms of hypoglycemia. What is the nurse’s best initial action?
Administer a glucagon injection
B. Offer 15 grams of a fast-acting carbohydrate
C. Check the patient’s blood glucose level
D. Notify the healthcare provider
Answer: C. Check the patient’s blood glucose level
The nurse is providing care for a patient in labor with an epidural in place. The patient suddenly reports chest pain and shortness of breath. What should the nurse suspect?
Amniotic fluid embolism
B. Placental abruption
C. Preterm labor
D. Hypotension
Answer: A. Amniotic fluid embolism
A nurse is caring for a patient with hypothyroidism. Which finding indicates a need for immediate intervention?
Constipation
B. Bradycardia
C. Cold intolerance
D. Altered level of consciousness
Answer: D. Altered level of consciousness
A patient with a spinal cord injury at T6 develops a pounding headache and flushed skin. What is the nurse’s priority intervention?
Administer antihypertensive medication
B. Raise the head of the bed
C. Check the patient’s blood glucose
D. Restrict fluid intake
Answer: B. Raise the head of the bed
A patient with a traumatic brain injury has a Glasgow Coma Scale score of 6. What does this indicate?
Mild brain injury
B. Moderate brain injury
C. Severe brain injury
D. Normal neurological function
Answer: C. Severe brain injury
A patient with chronic renal failure is prescribed erythropoietin. What is the expected therapeutic effect?
Increased appetite
B. Improved red blood cell production
C. Stabilized blood glucose levels
D. Reduced potassium levels
Answer: B. Improved red blood cell production
A nurse is teaching a patient with hypertension about dietary modifications. Which food should the patient avoid?
Bananas
B. Baked chicken
C. Canned soup
D. Fresh spinach
Answer: C. Canned soup
A patient with pancreatitis has a serum amylase level of 600 U/L. What is the nurse’s priority intervention?
Encourage a high-protein diet
B. Start total parenteral nutrition (TPN)
C. Administer IV fluids as prescribed
D. Position the patient flat in bed
Answer: C. Administer IV fluids as prescribed
A patient reports pain and tingling in the lower extremities after a lumbar puncture. What is the nurse’s best action?
Document the findings as expected
B. Reposition the patient to alleviate pressure
C. Notify the healthcare provider immediately
D. Administer prescribed pain medication
Answer: C. Notify the healthcare provider immediately
The nurse is caring for a patient with an ileostomy. Which finding requires immediate intervention?
Pale stoma
B. Liquid stool output
C. Red, moist stoma
D. Slight skin irritation around the stoma
Answer: A. Pale stoma
A nurse is monitoring a patient with hypovolemic shock. Which finding indicates the treatment is effective?
Blood pressure of 100/60 mmHg
B. Urine output of 10 mL/hr
C. Heart rate of 120 beats/min
D. Capillary refill time of 5 seconds
Answer: A. Blood pressure of 100/60 mmHg
A patient with rheumatoid arthritis is prescribed methotrexate. What should the nurse include in the teaching?
“Avoid live vaccines while taking this medication.”
B. “This medication may cause your hair to grow faster.”
C. “Take this medication on an empty stomach.”
D. “Increase your intake of high-potassium foods.”
Answer: A. “Avoid live vaccines while taking this medication.”
A nurse is caring for a patient with a chest tube. Which finding requires immediate intervention?
Continuous bubbling in the water seal chamber
B. Drainage of 50 mL/hr of serosanguinous fluid
C. Absence of fluctuation in the tubing during respiration
D. Mild pain at the insertion site
Answer: A. Continuous bubbling in the water seal chamber
A patient with myasthenia gravis reports increased muscle weakness. Which medication should the nurse anticipate administering?
Pyridostigmine
B. Atropine
C. Diazepam
D. Prednisone
Answer: A. Pyridostigmine
A patient with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 89%. What is the best nursing action?
Increase oxygen to 5 L/min
B. Maintain the oxygen at 2 L/min
C. Notify the healthcare provider
D. Administer a bronchodilator
Answer: B. Maintain the oxygen at 2 L/min
A patient is experiencing signs of compartment syndrome after a fracture. What is the nurse’s priority action?
Elevate the affected extremity
B. Prepare the patient for fasciotomy
C. Apply cold compresses
D. Assess distal pulses
Answer: B. Prepare the patient for fasciotomy
A patient with a deep vein thrombosis (DVT) is started on heparin therapy. What lab value should the nurse monitor to assess the effectiveness of the treatment?
Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Partial Thromboplastin Time (PTT)
D. Hemoglobin
Answer: C. Partial Thromboplastin Time (PTT)
A nurse is caring for a patient with diabetes insipidus. Which assessment finding requires immediate action?
Increased urine output
B. Blood glucose of 110 mg/dL
C. Serum sodium of 150 mEq/L
D. Weight gain of 2 pounds in one day
Answer: C. Serum sodium of 150 mEq/L
A patient with a stroke presents with dysphagia. What is the nurse’s priority action?
Perform oral care every 4 hours
B. Assess the patient’s gag reflex
C. Position the patient in a supine position
D. Start feeding with a nasogastric tube
Answer: B. Assess the patient’s gag reflex
The nurse is preparing to administer a unit of packed red blood cells. What is the first action?
Verify the patient’s identity with another nurse
B. Start the infusion with normal saline
C. Obtain the patient’s baseline vital signs
D. Check the blood for expiration date and compatibility
Answer: D. Check the blood for expiration date and compatibility
A patient with an acute myocardial infarction is receiving nitroglycerin infusion. Which finding requires immediate intervention?
Headache
B. Chest pain of 3/10
C. Blood pressure of 80/50 mmHg
D. Flushed skin
Answer: C. Blood pressure of 80/50 mmHg
The nurse is teaching a patient with asthma about the use of a metered-dose inhaler (MDI). Which statement by the patient indicates correct understanding?
“I will hold my breath for 3 seconds after inhaling the medication.”
B. “I need to exhale fully before using the inhaler.”
C. “I should rinse my mouth before using the inhaler.”
D. “I will use the inhaler immediately after eating.”
Answer: B. “I need to exhale fully before using the inhaler.”
A patient with cirrhosis is experiencing confusion. What is the nurse’s priority intervention?
Administer lactulose as prescribed
B. Restrict the patient’s fluid intake
C. Monitor blood glucose levels
D. Provide a high-protein diet
Answer: A. Administer lactulose as prescribed
A nurse is caring for a patient with septic shock. Which finding indicates the condition is worsening?
Blood pressure of 88/54 mmHg
B. Warm, flushed skin
C. Urine output of 50 mL/hr
D. Respiratory rate of 18 breaths/min
Answer: A. Blood pressure of 88/54 mmHg
The nurse is assessing a patient with Guillain-Barré syndrome. Which finding is most concerning?
Decreased deep tendon reflexes
B. Weakness in the lower extremities
C. Difficulty breathing
D. Numbness in the hands and feet
Answer: C. Difficulty breathing
A patient with chronic kidney disease reports severe itching. What is the most likely cause?
Increased bilirubin levels
B. High calcium levels
C. Elevated urea levels
D. Low phosphate levels
Answer: C. Elevated urea levels
The nurse is caring for a patient receiving total parenteral nutrition (TPN). What is the most important action?
Monitor the patient’s weight daily
B. Change the IV tubing every 48 hours
C. Check blood glucose levels regularly
D. Ensure the infusion is stopped at night
Answer: C. Check blood glucose levels regularly
A patient is admitted with suspected meningitis. What is the nurse’s priority action?
Initiate isolation precautions
B. Perform a lumbar puncture
C. Administer IV antibiotics
D. Monitor the patient’s urine output
Answer: A. Initiate isolation precautions
A patient with a chest tube has 200 mL of drainage in 1 hour. What is the nurse’s priority intervention?
Assess for signs of shock
B. Encourage deep breathing exercises
C. Document the findings as expected
D. Milk the chest tube to remove clots
Answer: A. Assess for signs of shock
The nurse is caring for a patient receiving digoxin. Which finding indicates digoxin toxicity?
Hypertension
B. Blurred vision with halos
C. Increased appetite
D. Tachycardia
Answer: B. Blurred vision with halos
A patient on mechanical ventilation is experiencing high-pressure alarms. What is the nurse’s priority action?
Check for kinks in the tubing
B. Increase the tidal volume
C. Administer a sedative
D. Suction the patient’s airway
Answer: A. Check for kinks in the tubing
A patient is admitted with a suspected bowel obstruction. What is the nurse’s initial action?
Insert a nasogastric tube
B. Administer pain medication
C. Provide a clear liquid diet
D. Monitor the patient’s weight
Answer: A. Insert a nasogastric tube
The nurse is preparing to administer vancomycin. What should the nurse monitor during the infusion?
Blood glucose levels
B. Serum potassium levels
C. Blood pressure and hearing
D. Respiratory rate
Answer: C. Blood pressure and hearing
A patient with a history of asthma is admitted with status asthmaticus. What is the nurse’s priority action?
Administer bronchodilators as prescribed
B. Perform chest physiotherapy
C. Administer IV fluids
D. Obtain a chest X-ray
Answer: A. Administer bronchodilators as prescribed
A patient with diabetes mellitus reports feeling shaky and lightheaded. What is the nurse’s best initial action?
Notify the healthcare provider
B. Administer IV dextrose
C. Offer a glass of orange juice
D. Check the patient’s blood glucose level
Answer: D. Check the patient’s blood glucose level
The nurse is caring for a patient with a newly placed tracheostomy. What is the priority assessment?
Skin condition around the stoma
B. Airway patency
C. Frequency of suctioning
D. Type of tracheostomy dressing
Answer: B. Airway patency
A patient with deep partial-thickness burns develops severe edema. What is the nurse’s priority intervention?
Elevate the affected extremities
B. Apply cold compresses
C. Administer pain medication
D. Monitor serum potassium levels
Answer: A. Elevate the affected extremities
A nurse is caring for a patient with hypothyroidism. Which symptom would the nurse expect to find?
Diarrhea
B. Tachycardia
C. Cold intolerance
D. Weight loss
Answer: C. Cold intolerance
A patient with chronic obstructive pulmonary disease (COPD) is experiencing increased dyspnea. What is the nurse’s priority intervention?
Increase the patient’s oxygen to 6 L/min via nasal cannula
B. Encourage pursed-lip breathing
C. Administer a bronchodilator
D. Obtain a chest X-ray
Answer: B. Encourage pursed-lip breathing
A patient receiving chemotherapy reports oral pain and difficulty eating. What should the nurse assess first?
Signs of infection in the oral cavity
B. Dietary intake over the past 24 hours
C. Level of hydration
D. Patient’s weight
Answer: A. Signs of infection in the oral cavity
A patient with a traumatic brain injury is exhibiting signs of increased intracranial pressure (ICP). Which finding is most concerning?
Blood pressure of 140/90 mmHg
B. Unequal pupil size
C. Heart rate of 78 bpm
D. Pain rating of 8/10
Answer: B. Unequal pupil size
A nurse is caring for a patient with a gastrostomy tube (G-tube). Which action is most important before administering medications?
Flush the tube with 30 mL of water
B. Elevate the head of the bed
C. Verify placement of the G-tube
D. Check the patient’s blood glucose
Answer: C. Verify placement of the G-tube
A patient with heart failure is prescribed furosemide. Which lab value should the nurse monitor?
Potassium
B. Hemoglobin
C. Platelets
D. Calcium
Answer: A. Potassium
A nurse is caring for a postoperative patient who is not voiding. What is the nurse’s priority action?
Administer prescribed diuretics
B. Palpate the bladder for distention
C. Encourage oral fluid intake
D. Insert a urinary catheter
Answer: B. Palpate the bladder for distention
A patient with cirrhosis is at risk for bleeding. What is the most important lab value for the nurse to monitor?
Hematocrit
B. Platelet count
C. Serum albumin
D. White blood cell count
Answer: B. Platelet count
The nurse is caring for a patient receiving opioid pain medication. What is the priority assessment?
Monitor for constipation
B. Check the respiratory rate
C. Assess pain levels every 2 hours
D. Monitor the patient’s blood pressure
Answer: B. Check the respiratory rate
A patient is prescribed warfarin therapy. Which statement indicates the patient needs further teaching?
“I will avoid foods high in vitamin K.”
B. “I will report any unusual bruising.”
C. “I can take aspirin if I have a headache.”
D. “I will have my INR checked regularly.”
Answer: C. “I can take aspirin if I have a headache.”
A nurse is assessing a patient with pneumonia. Which finding requires immediate intervention?
Fever of 102°F (38.9°C)
B. Oxygen saturation of 85%
C. Productive cough with green sputum
D. Crackles heard in the lower lobes
Answer: B. Oxygen saturation of 85%
A patient with a urinary tract infection (UTI) is prescribed ciprofloxacin. What should the nurse teach the patient?
“Avoid taking this medication with milk or antacids.”
B. “Stop the medication once symptoms improve.”
C. “Take the medication on an empty stomach.”
D. “Increase your intake of citrus fruits.”
Answer: A. “Avoid taking this medication with milk or antacids.”
The nurse is caring for a patient with a chest tube. What is an expected finding?
Continuous bubbling in the water seal chamber
B. Absence of drainage in the collection chamber
C. Intermittent bubbling in the water seal chamber
D. Drainage of 200 mL/hour for 2 hours
Answer: C. Intermittent bubbling in the water seal chamber
A patient is admitted with diabetic ketoacidosis (DKA). What is the nurse’s priority intervention?
Administer IV insulin as prescribed
B. Monitor blood glucose every 4 hours
C. Encourage oral fluids
D. Administer sodium bicarbonate
Answer: A. Administer IV insulin as prescribed
A patient with rheumatoid arthritis is prescribed methotrexate. What is an essential teaching point?
Avoid alcohol consumption
B. Take the medication with food
C. Increase intake of green leafy vegetables
D. Report frequent urination
Answer: A. Avoid alcohol consumption
A patient is receiving intravenous potassium chloride for hypokalemia. What is the priority nursing action?
Assess for redness at the IV site
B. Infuse the potassium at a rapid rate
C. Monitor for signs of hyperkalemia
D. Ensure the patient is on a cardiac monitor
Answer: D. Ensure the patient is on a cardiac monitor
The nurse is teaching a patient with hypertension about dietary modifications. Which statement indicates correct understanding?
“I can eat canned soups as long as I drain the liquid.”
B. “I will avoid foods high in sodium, like pickles and chips.”
C. “I should increase my protein intake to help manage my blood pressure.”
D. “I can season my food with soy sauce for flavor.”
Answer: B. “I will avoid foods high in sodium, like pickles and chips.”
A patient with anemia is prescribed iron supplements. What should the nurse include in the teaching?
“Take the iron supplement with milk.”
B. “Increase your intake of citrus fruits.”
C. “Expect your stools to be pale in color.”
D. “Take the supplement right before bedtime.”
Answer: B. “Increase your intake of citrus fruits.”
A nurse is preparing to administer insulin to a patient with diabetes. What is the correct action when mixing regular insulin and NPH insulin in one syringe?
Draw up the NPH insulin first
B. Mix the two insulins in the vial before drawing up
C. Draw up the regular insulin first
D. Shake the insulin vials before drawing up
Answer: C. Draw up the regular insulin first
A patient is admitted with acute pancreatitis. What is the nurse’s priority assessment?
Level of abdominal pain
B. Blood glucose levels
C. Serum amylase and lipase levels
D. Signs of hypovolemic shock
Answer: D. Signs of hypovolemic shock
Questions and Answers for Study Guide
Question:
Discuss the importance of critical thinking in nursing and how it influences the nursing process. Provide specific examples of how critical thinking can affect patient care outcomes.
Answer:
Critical thinking is an essential component of nursing practice as it empowers nurses to make informed decisions, analyze patient information, and formulate appropriate care plans. It involves the ability to question, evaluate, and assess situations systematically and logically.
The nursing process (assessment, diagnosis, planning, implementation, and evaluation) is deeply intertwined with critical thinking. In the assessment phase, critical thinking allows the nurse to gather and interpret data more effectively, recognizing subtle signs that might otherwise be overlooked. For example, a nurse caring for a post-operative patient might identify signs of infection early by critically evaluating wound appearance and assessing vital signs against baseline data.
During the diagnosis phase, critical thinking helps the nurse to analyze assessment data and form a diagnosis that accurately reflects the patient’s condition. For example, a nurse who critically examines a patient’s blood pressure readings, history of hypertension, and symptoms might identify the need for further evaluation and intervention, leading to a diagnosis of “risk for hypertensive crisis.”
In the planning and implementation phases, critical thinking supports decision-making regarding the best interventions. For example, a nurse caring for a diabetic patient experiencing fluctuating blood glucose levels may critically evaluate the effectiveness of the prescribed insulin regimen and collaborate with the healthcare team to adjust dosages accordingly.
Finally, in the evaluation phase, critical thinking helps nurses assess the outcomes of interventions. For example, if a patient’s wound healing is slower than expected, the nurse might critically evaluate the patient’s nutritional intake, antibiotic regimen, and potential comorbidities, leading to a more tailored and effective treatment plan.
Overall, critical thinking enhances clinical judgment, improves patient safety, and promotes positive health outcomes by ensuring that interventions are timely, appropriate, and based on a comprehensive understanding of the patient’s condition.
Question:
Explain the concept of prioritization in nursing care. How does prioritizing tasks effectively improve patient safety and care quality?
Answer:
Prioritization in nursing refers to the process of organizing patient care activities based on their level of importance, urgency, and potential impact on patient outcomes. It ensures that the most critical tasks are addressed first, promoting patient safety and improving the quality of care.
Effective prioritization starts with recognizing the most urgent needs of a patient. Using frameworks like Maslow’s Hierarchy of Needs or the ABC (Airway, Breathing, Circulation) framework, nurses can decide which actions are life-threatening and must be addressed immediately. For example, if a patient in the emergency room is exhibiting signs of respiratory distress, a nurse will prioritize interventions to ensure the patient’s airway is open and they are breathing effectively, rather than addressing less immediate concerns like pain management.
Additionally, prioritization is closely linked to the assessment phase of the nursing process. By systematically evaluating patients’ conditions and considering factors like severity, potential complications, and patient preferences, nurses can determine which tasks must be completed first. For instance, a nurse caring for multiple patients in a hospital unit may identify that a postoperative patient with unstable vital signs should receive attention before a patient who is stable and only requires routine medication administration.
Effective prioritization also prevents errors and reduces the likelihood of neglecting important aspects of care. By planning ahead and setting realistic goals, nurses can ensure that they are available to attend to high-priority patients and avoid delays in essential care. For example, when managing a group of patients, a nurse may delegate tasks to other healthcare team members (such as a nursing assistant for vital sign monitoring), which helps ensure the workload is distributed effectively and that patients’ critical needs are addressed promptly.
By improving prioritization, nurses not only safeguard patient well-being but also optimize the use of available resources, contribute to more efficient care delivery, and enhance patient satisfaction.
Question:
Describe the role of clinical judgment in nursing and provide an example of how it helps improve patient care outcomes.
Answer:
Clinical judgment refers to the nurse’s ability to make informed decisions about patient care based on their knowledge, experience, and critical thinking. It involves the integration of evidence-based practice, patient preferences, and clinical expertise to determine the best course of action for a patient.
The role of clinical judgment in nursing is crucial because it ensures that nurses are making decisions that are both safe and effective for the patient. Clinical judgment is not just about following protocols but also about being able to adapt care plans when faced with unexpected changes in a patient’s condition. For instance, a nurse caring for a post-surgical patient might initially follow the prescribed pain management plan. However, if the patient develops nausea and vomiting, the nurse uses clinical judgment to reassess the situation, altering the medication regimen and possibly notifying the healthcare provider about the need for an alternative pain management approach.
An example of clinical judgment in action can be seen in the case of a patient with congestive heart failure (CHF) presenting with shortness of breath. A nurse must quickly assess the patient’s symptoms, review diagnostic tests such as an echocardiogram or chest X-ray, and recognize early signs of fluid overload. Based on their clinical judgment, the nurse might prioritize interventions such as administering diuretics and oxygen therapy to relieve the patient’s symptoms while simultaneously notifying the healthcare provider for further evaluation.
Clinical judgment enhances patient care outcomes by improving the accuracy of assessments, promoting timely interventions, and ensuring that nurses are responsive to the dynamic needs of their patients. It is a process that involves ongoing evaluation and adjustment to care plans to achieve the best possible results.
Question:
Discuss how effective communication skills contribute to critical thinking and decision-making in nursing practice. Include examples of both verbal and non-verbal communication in your response.
Answer:
Effective communication is a cornerstone of critical thinking and decision-making in nursing practice. It ensures that nurses accurately collect patient data, collaborate with the healthcare team, and convey important information to patients and their families. Clear and precise communication enables nurses to think critically and make informed decisions that enhance patient care.
Verbal communication is central to nursing practice, as it allows nurses to exchange information with patients, families, and other healthcare professionals. Through active listening, nurses can understand patients’ concerns, symptoms, and experiences, which informs critical thinking and clinical decisions. For example, when assessing a patient with abdominal pain, a nurse might ask specific questions about the pain’s location, duration, and intensity, which helps in forming a diagnosis and planning appropriate interventions. In this scenario, the nurse’s ability to ask focused questions and interpret responses accurately is essential for making sound clinical judgments.
Non-verbal communication, such as body language, facial expressions, and gestures, is equally important. A nurse’s posture, eye contact, and facial expressions can convey empathy and reassurance, helping patients feel heard and understood. For instance, a nurse who uses a calm and reassuring tone when explaining a medical procedure can help alleviate a patient’s anxiety, fostering trust and cooperation. Additionally, non-verbal cues can sometimes provide critical information that verbal communication might not, such as a patient’s reluctance to make eye contact indicating distress or discomfort.
Together, verbal and non-verbal communication facilitate the gathering of information and the collaborative decision-making process. By employing effective communication strategies, nurses are better equipped to assess patient needs, prioritize care, and work with the healthcare team to implement the most appropriate interventions, ultimately improving patient outcomes.