1. A patient with cirrhosis presents with confusion and lethargy. Which
intervention should the nurse implement first?
A. Administer lactulose as prescribed.
B. Restrict dietary protein intake.
C. Check ammonia levels.
D. Monitor for signs of infection.
Answer and Rationale:
A. Administer lactulose as prescribed.
Rationale: Lactulose reduces ammonia levels, addressing hepatic
encephalopathy and improving mental status.
2. A patient with type 1 diabetes has a blood glucose of 45 mg/dL and
is alert but shaky. What is the nurse’s priority intervention?
A. Administer 1 mg of glucagon IM.
B. Provide 15 g of fast-acting carbohydrates.
C. Start an IV dextrose infusion.
D. Recheck blood glucose in 15 minutes.
Answer and Rationale:
B. Provide 15 g of fast-acting carbohydrates.
Rationale: The patient is alert, so oral carbohydrates are the
appropriate and fastest intervention for hypoglycemia.
,3. A patient with end-stage renal disease reports severe itching. What
intervention is most appropriate?
A. Administer prescribed antihistamines.
B. Encourage increased water intake.
C. Monitor phosphorus levels.
D. Apply emollients to the skin.
Answer and Rationale:
C. Monitor phosphorus levels.
Rationale: Severe itching in renal patients is often due to
hyperphosphatemia. Addressing the cause is more effective than
symptom management alone.
4. A patient recovering from a thoracotomy has a respiratory rate of 28
breaths/min and is using accessory muscles to breathe. What is the
nurse’s first action?
A. Increase oxygen delivery.
B. Assess pain level and provide analgesia.
C. Perform a respiratory assessment.
D. Notify the healthcare provider.
Answer and Rationale:
C. Perform a respiratory assessment.
, Rationale: Identifying the underlying cause of respiratory distress is
essential before intervening.
5. 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.
6. The nurse notices a peaked T wave on the ECG of a patient with
chronic kidney disease. What is the nurse’s priority?
A. Notify the healthcare provider.
B. Administer sodium bicarbonate.
C. Administer calcium gluconate.
D. Check the patient’s potassium level.
Answer and Rationale:
D. Check the patient’s potassium level.
intervention should the nurse implement first?
A. Administer lactulose as prescribed.
B. Restrict dietary protein intake.
C. Check ammonia levels.
D. Monitor for signs of infection.
Answer and Rationale:
A. Administer lactulose as prescribed.
Rationale: Lactulose reduces ammonia levels, addressing hepatic
encephalopathy and improving mental status.
2. A patient with type 1 diabetes has a blood glucose of 45 mg/dL and
is alert but shaky. What is the nurse’s priority intervention?
A. Administer 1 mg of glucagon IM.
B. Provide 15 g of fast-acting carbohydrates.
C. Start an IV dextrose infusion.
D. Recheck blood glucose in 15 minutes.
Answer and Rationale:
B. Provide 15 g of fast-acting carbohydrates.
Rationale: The patient is alert, so oral carbohydrates are the
appropriate and fastest intervention for hypoglycemia.
,3. A patient with end-stage renal disease reports severe itching. What
intervention is most appropriate?
A. Administer prescribed antihistamines.
B. Encourage increased water intake.
C. Monitor phosphorus levels.
D. Apply emollients to the skin.
Answer and Rationale:
C. Monitor phosphorus levels.
Rationale: Severe itching in renal patients is often due to
hyperphosphatemia. Addressing the cause is more effective than
symptom management alone.
4. A patient recovering from a thoracotomy has a respiratory rate of 28
breaths/min and is using accessory muscles to breathe. What is the
nurse’s first action?
A. Increase oxygen delivery.
B. Assess pain level and provide analgesia.
C. Perform a respiratory assessment.
D. Notify the healthcare provider.
Answer and Rationale:
C. Perform a respiratory assessment.
, Rationale: Identifying the underlying cause of respiratory distress is
essential before intervening.
5. 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.
6. The nurse notices a peaked T wave on the ECG of a patient with
chronic kidney disease. What is the nurse’s priority?
A. Notify the healthcare provider.
B. Administer sodium bicarbonate.
C. Administer calcium gluconate.
D. Check the patient’s potassium level.
Answer and Rationale:
D. Check the patient’s potassium level.
