A nurse is assessing a patient with chest pain. What is the priority action by the nurse?
A) Obtain a 12-lead ECG.
B) Administer nitroglycerin.
C) Obtain vital signs.
D) Call the physician.
Answer: A) Obtain a 12-lead ECG.
Rationale: The priority action is to obtain a 12-lead ECG to assess fo...
A nurse is assessing a patient with chest pain. What is the priority action by the nurse?
A) Obtain a 12-lead ECG.
B) Administer nitroglycerin.
C) Obtain vital signs.
D) Call the physician.
Answer: A) Obtain a 12-lead ECG.
Rationale: The priority action is to obtain a 12-lead ECG to assess for any cardiac abnormalities.
Early identification of cardiac issues is crucial in managing chest pain.
Question 2
Which of the following is an example of critical thinking in nursing practice?
A) Following a checklist during patient care.
B) Analyzing patient data to identify potential complications.
C) Adhering to hospital policies without question.
D) Relying solely on previous experiences.
Answer: B) Analyzing patient data to identify potential complications.
Rationale: Critical thinking involves evaluating and synthesizing information to make informed
decisions, rather than just following protocols or personal experience.
Question 3
A nurse is preparing to discharge a patient with diabetes. What is the most important teaching
point for this patient?
A) The need to monitor blood glucose levels regularly.
B) The importance of a low-sodium diet.
C) The benefits of aerobic exercise.
D) How to administer insulin.
Answer: A) The need to monitor blood glucose levels regularly.
Rationale: Regular monitoring of blood glucose levels is essential for managing diabetes and
preventing complications.
,Question 4
During a patient assessment, the nurse notes that the patient is using accessory muscles to
breathe. What should the nurse do first?
A) Administer bronchodilator medication.
B) Assess oxygen saturation levels.
C) Position the patient for comfort.
D) Notify the healthcare provider.
Answer: B) Assess oxygen saturation levels.
Rationale: Assessing oxygen saturation is crucial to determine the severity of the respiratory
distress and guide further interventions.
Question 5
In prioritizing care for a group of patients, which patient should the nurse assess first?
A) A patient scheduled for a routine procedure.
B) A patient with stable vital signs.
C) A patient experiencing chest pain.
D) A patient asking for pain medication.
Answer: C) A patient experiencing chest pain.
Rationale: Chest pain is a potentially life-threatening condition that requires immediate
assessment and intervention.
Question 6
A nurse is caring for a patient who is 24 hours postoperative and reports increased pain. What is
the nurse's best initial action?
A) Administer prescribed analgesics.
B) Assess the surgical site for complications.
C) Reassure the patient that pain is normal.
D) Notify the healthcare provider.
Answer: B) Assess the surgical site for complications.
Rationale: Before administering pain medication, the nurse should assess for potential
complications that may require intervention.
, Question 7
Which of the following is a critical component of the nursing process that enhances clinical
judgment?
A) Documentation
B) Evaluation
C) Planning
D) Assessment
Answer: D) Assessment
Rationale: The assessment phase is critical in collecting data that informs the nursing diagnosis
and guides subsequent nursing interventions.
Question 8
A nurse is caring for a patient with pneumonia. What finding would indicate a potential
complication?
A) Increased respiratory rate
B) Wheezing on auscultation
C) Decreased breath sounds on one side
D) Productive cough
Answer: C) Decreased breath sounds on one side
Rationale: Decreased breath sounds may indicate the presence of a pleural effusion or other
complications that require further investigation.
Question 9
Which nursing action demonstrates effective clinical judgment when managing a patient with a
new diagnosis of heart failure?
A) Providing a detailed brochure about heart failure.
B) Monitoring daily weights.
C) Encouraging the patient to exercise.
D) Teaching about dietary restrictions.
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