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.
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 SpOâ‚‚ of 88% on 2L NC.
D. A heart failure client with 2+ pedal edema.
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.
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.
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.