1.Easy
A nursing assistant reports four findings. Which one should the nurse check first?
- AA patient who wants to phone a relative
- BA patient who asks for another blanket
- CA patient who suddenly cannot move their right arm
- DA patient whose breakfast tray is not finished
2.Easy
In which situation can a pulse oximeter give a falsely normal reading?
- AA warm, well-perfused finger
- BA healthy adult at rest
- CA patient breathing room air normally
- DCarbon monoxide poisoning
3.Easy
Using the rule of nines, what percentage of body surface does one whole arm represent in an adult?
- A18%
- B36%
- C1%
- D9%
4.Medium
On a pediatric unit, which child does the nurse assess first?
- AA child with asthma who is now quiet with very little air movement
- BA child with croup who has a barking cough but no stridor at rest
- CA child in a new arm cast with pink, warm fingers and pain of 5/10
- DA child with a temperature of 38.2 °C after vaccination
5.Medium
A nurse has called the rapid response team for a deteriorating patient. What should the nurse do while waiting for the team?
- AStay with the patient, give oxygen as prescribed and have recent vital signs ready
- BGo to the station to finish documentation for other patients
- CLeave the patient for a few minutes to find the relatives and explain what is happening
- DGive a dose of every as-needed medication on the chart
6.Medium
An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?
- ARaise all four bed rails so the patient cannot climb out
- BGive a sedative from the as-needed list without first assessing the patient
- CCheck for pain, thirst or a full bladder, and offer toileting
- DApply wrist restraints for the rest of the night
7.Hard
A patient is receiving IV potassium chloride through a peripheral line and complains of burning at the site, which looks red. What does the nurse do first?
- AIncrease the infusion rate to finish the dose sooner
- BTell the patient that burning is expected and continue
- CApply a warm pack and continue the infusion
- DStop the infusion and assess the IV site
8.Hard
At 08:00 a nurse has four tasks. Which order is best?
- AGive insulin with breakfast, update care plans, check the patient with a falling SpO₂, give routine medications
- BGive routine medications, check the patient with a falling SpO₂, update care plans, give insulin with breakfast
- CCheck the patient with a falling SpO₂, give insulin with breakfast, give routine medications, update care plans
- DUpdate care plans, give insulin with breakfast, give routine medications, check the patient with a falling SpO₂
Answer key
- 1. C · A patient who suddenly cannot move their right arm
- 2. D · Carbon monoxide poisoning
- 3. D · 9%
- 4. A · A child with asthma who is now quiet with very little air movement
- 5. A · Stay with the patient, give oxygen as prescribed and have recent vital signs ready
- 6. C · Check for pain, thirst or a full bladder, and offer toileting
- 7. D · Stop the infusion and assess the IV site
- 8. C · Check the patient with a falling SpO₂, give insulin with breakfast, give routine medications, update care plans
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