26 original SNLE questions on medical nursing, each with an explanation for all four options. Part of Adult Nursing, worth 40% of the Saudi Nursing Licensure Examination.
Q01 / 10medium0 correct
Adult Nursingmediumq004
A 62-year-old patient with type 2 diabetes presents with a serum glucose of 640 mg/dL, serum osmolality of 330 mOsm/kg, pH 7.36, and negative serum ketones. Which nursing intervention should the nurse anticipate as the initial priority?
All 26 questions
Every question below, with the reasoning for all four options. Try to answer before you open one.
Medical nursing · medium
A 62-year-old patient with type 2 diabetes presents with a serum glucose of 640 mg/dL, serum osmolality of 330 mOsm/kg, pH 7.36, and negative serum ketones. Which nursing intervention should the nurse anticipate as the initial priority?
ABegin isotonic intravenous fluid resuscitation
BAdminister a subcutaneous rapid-acting insulin sliding scale dose
CAdminister intravenous sodium bicarbonate
DRestrict oral fluids and monitor hourly blood glucose only
Show the answer and why the others fail
Answer: A. Begin isotonic intravenous fluid resuscitation
A — correct
Hyperosmolar hyperglycemic state produces profound osmotic diuresis and severe volume depletion. Aggressive isotonic fluid replacement is the first-line treatment and by itself lowers glucose substantially before insulin infusion is titrated.
B
Subcutaneous absorption is unreliable in a dehydrated, poorly perfused patient; a controlled intravenous insulin infusion is used, and only after fluid resuscitation is underway.
C
There is no significant acidosis (pH 7.36) and bicarbonate is not indicated; this picture is hyperosmolar hyperglycemic state, not ketoacidosis.
D
Fluid restriction worsens the underlying hypovolemia and hyperosmolality; monitoring alone does not treat the emergency.
TakeawayIn hyperosmolar hyperglycemic state, fluid resuscitation comes before insulin — the patient's core problem is profound dehydration.
Medical nursing · medium
A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Arterial blood gas on room air shows pH 7.31, PaCO2 62 mmHg, HCO3 30 mEq/L, PaO2 52 mmHg. Which oxygen therapy approach is most appropriate?
AApply a non-rebreather mask at 15 L/min
BTarget an oxygen saturation of 98 to 100 percent with a simple face mask
CTitrate controlled oxygen to a target saturation of 88 to 92 percent
DWithhold oxygen to avoid suppressing the hypoxic respiratory drive
Show the answer and why the others fail
Answer: C. Titrate controlled oxygen to a target saturation of 88 to 92 percent
A
High-flow uncontrolled oxygen in a chronically hypercapnic patient can worsen CO2 retention through ventilation-perfusion mismatch and the Haldane effect.
B
Overshooting saturation in COPD increases the risk of worsening hypercapnia and acidosis, and confers no benefit.
C — correct
Patients at risk of hypercapnic respiratory failure are managed with a target SpO2 of 88 to 92 percent, which corrects dangerous hypoxemia while minimizing CO2 retention. This is the current standard for COPD exacerbation.
D
Withholding oxygen from a hypoxemic patient is dangerous. Hypoxia kills faster than hypercapnia; oxygen is given, but titrated.
TakeawayIn COPD with hypercapnic respiratory failure risk, give oxygen but titrate it to SpO2 88 to 92 percent — never withhold it entirely.
Medical nursing · medium
A 68-year-old male with a history of chronic obstructive pulmonary disease (COPD) is admitted with increasing shortness of breath and confusion. He is on 2 L/min oxygen via nasal cannula. Arterial blood gas (ABG) results are: pH 7.32, PaCO2 60 mm Hg, HCO3- 30 mEq/L, PaO2 68 mm Hg. Which of the following best describes the acid-base disturbance?
APartially compensated respiratory acidosis
BMetabolic alkalosis with respiratory compensation
CFully compensated respiratory acidosis
DUncompensated respiratory acidosis
Show the answer and why the others fail
Answer: A. Partially compensated respiratory acidosis
A — correct
The pH is low (acidosis), the PaCO2 is high (respiratory cause), and the HCO3- is elevated (metabolic compensation). However, the pH remains abnormal, meaning compensation is incomplete, making this a partially compensated respiratory acidosis.
B
The primary disturbance is a low pH (acidosis), not alkalosis. Metabolic alkalosis would present with a high pH and high HCO3-, and the respiratory compensation would be an elevated PaCO2, but the pH would be high, not low.
C
In fully compensated respiratory acidosis, the pH would be within the normal range (7.35-7.45) due to sufficient renal retention of bicarbonate. Here, the pH is 7.32, still acidotic, so compensation is not complete.
D
In uncompensated respiratory acidosis, the HCO3- would be within normal limits (22-26 mEq/L) because the kidneys have not yet had time to retain bicarbonate. Here, the HCO3- is elevated, indicating renal compensation is occurring.
TakeawayIn chronic respiratory acidosis, the kidneys compensate by retaining bicarbonate. If the pH remains outside the normal range despite an elevated HCO3-, the condition is partially compensated. Full compensation returns pH to normal.
Medical nursing · medium
A 55-year-old patient with type 2 diabetes mellitus is admitted with acute abdominal pain. The healthcare provider orders a CT scan with intravenous contrast. The patient's current medications include metformin 1000 mg twice daily. Baseline laboratory results show serum creatinine 0.9 mg/dL (eGFR >60 mL/min/1.73 m²) and no history of acute kidney injury. Which action should the nurse take regarding the metformin?
AAdminister metformin with a high-carbohydrate meal just before the scan.
BAdminister the metformin as scheduled before the scan.
CHold the metformin before the scan and for 48 hours after the procedure.
DHold metformin only if the patient's blood glucose is below 70 mg/dL.
Show the answer and why the others fail
Answer: B. Administer the metformin as scheduled before the scan.
A
The timing of metformin with meals does not mitigate the risk of contrast-induced nephropathy; the decision to hold metformin is based solely on renal function.
B — correct
Current guidelines (ACR 2023, ADA) state that metformin does not need to be withheld before intravenous contrast in patients with eGFR ≥30 mL/min/1.73 m² and no acute kidney injury, as the risk of lactic acidosis is extremely low.
C
Routine 48-hour withholding is an outdated practice; current evidence shows it is unnecessary in patients with normal renal function and may lead to unnecessary hyperglycemia.
D
The decision to withhold metformin is based on renal function and risk of lactic acidosis, not on current blood glucose levels.
TakeawayCurrent guidelines (ACR Manual on Contrast Media, 2023) recommend that metformin can be continued safely in patients with eGFR ≥30 mL/min/1.73 m² and no acute kidney injury, eliminating the need for routine pre-procedural withholding.
Medical nursing · medium
A 52-year-old male with a history of alcohol use disorder presents to the emergency department with severe epigastric pain radiating to the back, nausea, and vomiting for 12 hours. Vital signs: heart rate 112 bpm, blood pressure 90/60 mm Hg, respiratory rate 22/min, temperature 38.2°C. Laboratory results show serum lipase 850 U/L (normal <160 U/L). What is the priority nursing intervention?
AInitiate intravenous fluid resuscitation
BAdminister intravenous hydromorphone for pain relief
CInitiate total parenteral nutrition
DInsert a nasogastric tube for gastric decompression
Show the answer and why the others fail
Answer: A. Initiate intravenous fluid resuscitation
A — correct
Moderate intravenous fluid resuscitation with a balanced crystalloid such as lactated Ringer's is the priority intervention to correct hypovolemia, maintain pancreatic perfusion, and prevent progression to severe pancreatitis.
B
Pain management is important in acute pancreatitis, but in a patient with hypotension and tachycardia indicating hypovolemia, fluid resuscitation takes priority to restore hemodynamic stability and prevent organ hypoperfusion.
C
Total parenteral nutrition is not the immediate priority. Current guidelines recommend initiating enteral nutrition within 24–48 hours if oral intake is not tolerated, and TPN is reserved for when enteral nutrition is contraindicated or not feasible.
D
Routine nasogastric tube insertion is not indicated in acute pancreatitis unless the patient has persistent vomiting, ileus, or severe abdominal distension. It does not address the immediate hemodynamic compromise.
TakeawayIn acute pancreatitis with hypovolemia, moderate intravenous fluid resuscitation with a balanced crystalloid such as lactated Ringer's is the priority to correct hypovolemia and prevent organ hypoperfusion.
Medical nursing · medium
A 65-year-old patient with stage 4 chronic kidney disease is admitted with generalized weakness and palpitations. The nurse notes tall, peaked T waves on the cardiac monitor. Serum potassium level is 6.8 mEq/L. A patent intravenous line is in place. Which action should the nurse take first?
AAdminister intravenous calcium gluconate.
BAdminister oral sodium zirconium cyclosilicate.
CAdminister intravenous regular insulin and dextrose.
DPrepare the patient for emergency hemodialysis.
Show the answer and why the others fail
Answer: A. Administer intravenous calcium gluconate.
A — correct
Calcium gluconate directly antagonizes the cardiac effects of hyperkalemia, stabilizing the myocardial cell membrane and preventing life-threatening arrhythmias. It is the priority intervention when ECG changes are present.
B
Sodium zirconium cyclosilicate is a potassium binder that removes potassium via the gastrointestinal tract, but its onset is too slow (about 1 hour) for emergency management of ECG changes.
C
Insulin and dextrose shift potassium intracellularly, lowering serum levels, but they do not provide immediate cardiac membrane stabilization. They are often given concurrently with calcium, but calcium remains the first priority.
D
Hemodialysis effectively removes potassium, but preparation takes time. Calcium must be given first to protect the heart while dialysis is arranged.
TakeawayIn hyperkalemia with ECG changes, the immediate priority is to stabilize the cardiac membrane with intravenous calcium (gluconate or chloride) to prevent life-threatening arrhythmias, even before initiating potassium-lowering therapies.
Medical nursing · medium
A 58-year-old patient with a history of alcoholic cirrhosis is admitted with increasing confusion and lethargy over the past 24 hours. The nurse notes flapping tremors of the hands when the patient extends the arms. Serum ammonia level is 110 µmol/L (normal: 11–35 µmol/L). Which of the following is the priority nursing action?
ARestrict dietary protein to 20 g/day
BAdminister neomycin as prescribed
CInitiate a fluid restriction of 1.5 L/day
DAdminister the prescribed lactulose
Show the answer and why the others fail
Answer: D. Administer the prescribed lactulose
A
Protein restriction is no longer routinely recommended in hepatic encephalopathy because it can worsen malnutrition and does not improve outcomes. Current guidelines emphasize maintaining adequate protein intake.
B
Neomycin is a second-line antibiotic that reduces gut ammonia-producing bacteria, but it is not the priority initial therapy. Lactulose is the first-line treatment and should be given promptly to lower ammonia levels.
C
Fluid restriction is used for hyponatremia or fluid overload, not for hepatic encephalopathy. The patient's confusion is due to elevated ammonia, not fluid imbalance.
D — correct
Lactulose is the first-line treatment for hepatic encephalopathy. It acidifies the colon, converting ammonia (NH3) to ammonium (NH4+), which is poorly absorbed, thereby reducing serum ammonia levels and improving neurological symptoms.
TakeawayLactulose is the first-line therapy for hepatic encephalopathy; it works by acidifying the colon to trap ammonia and promote its excretion.
Medical nursing · medium
A 35-year-old man presents to the emergency department with sharp, pleuritic chest pain that worsens when he lies flat and improves when he sits forward. He reports a recent upper respiratory infection. Vital signs are stable. ECG shows diffuse ST-segment elevation. Which medication does the nurse anticipate administering first?
ANitroglycerin sublingual
BMorphine sulfate IV
CIbuprofen 600 mg orally
DAspirin 325 mg chewed
Show the answer and why the others fail
Answer: C. Ibuprofen 600 mg orally
A
Nitroglycerin is indicated for anginal pain due to coronary artery disease. It is ineffective for the inflammatory pain of pericarditis and does not address the underlying inflammation.
B
Morphine is reserved for severe pain refractory to NSAIDs and is not a first-line agent for pericarditis. It does not treat the underlying inflammation.
C — correct
Ibuprofen is a first-line NSAID for acute pericarditis, providing anti-inflammatory and analgesic effects. The dose is appropriate for treating pericarditis.
D
Aspirin is a first-line NSAID for pericarditis, but the 325 mg chewed formulation is an acute coronary syndrome dose. Pericarditis requires high-dose aspirin (e.g., 750–1000 mg every 8 hours) for anti-inflammatory effect, making this regimen inappropriate.
TakeawayFirst-line therapy for acute pericarditis includes an NSAID (e.g., ibuprofen) plus colchicine to reduce recurrence; opioids are reserved for refractory pain.
Medical nursing · medium
A 25-year-old patient with a history of asthma presents to the emergency department with severe dyspnea, audible wheezing, and use of accessory muscles. Oxygen saturation is 91% on room air. The nurse applies oxygen via a non-rebreather mask. Which of the following should the nurse do next?
AAdminister intravenous methylprednisolone
BAdminister inhaled albuterol
CAdminister inhaled fluticasone
DObtain a portable chest x-ray
Show the answer and why the others fail
Answer: B. Administer inhaled albuterol
A
Systemic corticosteroids reduce airway inflammation but have a delayed onset of action (hours) and are not the immediate next step after oxygen.
B — correct
Short-acting beta-agonists such as albuterol are the first-line bronchodilators for acute asthma exacerbations and should be given promptly after oxygen is initiated.
C
Inhaled corticosteroids are maintenance therapy for chronic asthma and do not provide rapid bronchodilation needed in an acute exacerbation.
D
Imaging is not a priority during an acute exacerbation; airway management and bronchodilation take precedence.
TakeawayIn acute asthma exacerbation, after initiating supplemental oxygen to correct hypoxemia, the next priority is to administer a short-acting beta-agonist (e.g., albuterol) to relieve bronchospasm.
Medical nursing · easy
A 55-year-old male with a history of gout and peptic ulcer disease presents to the clinic with sudden onset of severe pain, erythema, and swelling in his right great toe that began last night. He rates the pain as 9/10. He is currently taking allopurinol 300 mg daily. Which medication should the nurse anticipate administering for this acute episode?
AAllopurinol
BIndomethacin
CFebuxostat
DColchicine
Show the answer and why the others fail
Answer: D. Colchicine
A
Allopurinol is a xanthine oxidase inhibitor used for long-term urate-lowering therapy; it does not treat acute gout pain and should be continued during a flare if already prescribed.
B
Indomethacin is an NSAID that can effectively treat acute gout pain, but it should be avoided in patients with a history of peptic ulcer disease because it increases the risk of gastrointestinal complications.
C
Febuxostat is a xanthine oxidase inhibitor indicated for chronic urate-lowering therapy; it does not treat acute gout symptoms and is not used for acute flare management.
D — correct
Colchicine inhibits microtubule polymerization and neutrophil chemotaxis, thereby reducing the inflammatory response in acute gout; it is a first-line option when NSAIDs are relatively contraindicated due to peptic ulcer disease history.
TakeawayAcute gout flares are managed with colchicine, NSAIDs, or corticosteroids. In patients with a history of peptic ulcer disease, NSAIDs should be avoided due to increased gastrointestinal risk, making colchicine or corticosteroids preferred. Urate-lowering therapies like allopurinol should be continued during an acute flare if already prescribed.
Medical nursing · medium
A 35-year-old woman with a known allergy to bee stings is brought to the emergency department after being stung on the arm. She is anxious, with diffuse urticaria, audible wheezing, and a blood pressure of 85/50 mm Hg. Which of the following should the nurse administer first?
AAlbuterol 2.5 mg via nebulizer
BEpinephrine 0.3 mg IM
CDiphenhydramine 50 mg IV
D0.9% sodium chloride 500 mL IV bolus
Show the answer and why the others fail
Answer: B. Epinephrine 0.3 mg IM
A
Albuterol is a bronchodilator that may relieve wheezing but does not treat hypotension or the underlying anaphylactic reaction; it is an adjunct after epinephrine if bronchospasm persists.
B — correct
Epinephrine is the first-line treatment for anaphylaxis. It acts on alpha-adrenergic receptors to reverse vasodilation and hypotension, and on beta-adrenergic receptors to relieve bronchospasm and reduce mediator release, addressing the immediate life threats.
C
Diphenhydramine is an H1-antihistamine that relieves itching and urticaria but does not reverse hypotension or bronchospasm; it is a second-line adjunct, not the priority in life-threatening anaphylaxis.
D
Intravenous fluids help restore intravascular volume in hypotension, but they do not reverse vasodilation or bronchoconstriction as rapidly as epinephrine; fluid resuscitation is a secondary intervention.
TakeawayIn anaphylaxis with hypotension or respiratory distress, intramuscular epinephrine into the anterolateral thigh is the immediate priority to prevent progression to shock.
Medical nursing · medium
A 68-year-old man is brought to the emergency department with sudden onset of right-sided weakness and difficulty speaking that began 90 minutes ago. A non-contrast CT scan of the head shows no hemorrhage. He has a history of hypertension and takes lisinopril. Vital signs: blood pressure 160/90 mm Hg, heart rate 88/min, respiratory rate 18/min, oxygen saturation 97% on room air. Neurological examination confirms right hemiparesis and expressive aphasia. Which of the following is the priority intervention?
AAdminister IV alteplase
BRefer for urgent carotid endarterectomy
CAdminister aspirin 300 mg orally
DInitiate continuous heparin infusion
Show the answer and why the others fail
Answer: A. Administer IV alteplase
A — correct
IV alteplase is the standard of care for acute ischemic stroke within 4.5 hours of symptom onset in eligible patients, as it can restore cerebral perfusion and improve neurological outcomes. The CT ruled out hemorrhage, and based on the provided data, there are no identified contraindications.
B
Carotid endarterectomy is a secondary prevention measure for patients with significant carotid stenosis, not an acute intervention for stroke. It is not indicated in the emergency management of acute ischemic stroke.
C
Aspirin is indicated within 24 to 48 hours after symptom onset in acute ischemic stroke, particularly if alteplase is contraindicated or not given, but it is not the priority intervention in the hyperacute setting when the patient is eligible for thrombolysis.
D
Heparin is not routinely recommended in acute ischemic stroke due to increased risk of hemorrhagic transformation without clear benefit; it is not the priority intervention.
TakeawayIn acute ischemic stroke, IV alteplase should be administered within 4.5 hours of symptom onset to improve neurological outcomes, after excluding intracranial hemorrhage and other contraindications.
Medical nursing · medium
A 72-year-old patient with heart failure is taking digoxin 0.125 mg daily and furosemide 40 mg twice daily. The patient reports nausea, anorexia, and seeing yellow-green halos around lights. Vital signs: heart rate 52 bpm, blood pressure 110/70 mm Hg. ECG shows sinus bradycardia with occasional premature ventricular contractions. Which action should the nurse take first?
AAdminister a potassium chloride supplement.
BAdminister atropine 0.5 mg IV push.
CHold the digoxin and notify the healthcare provider.
DPrepare the patient for transcutaneous pacing.
Show the answer and why the others fail
Answer: C. Hold the digoxin and notify the healthcare provider.
A
Potassium supplements should not be given without knowing the serum potassium level. While furosemide-induced hypokalemia may have contributed to toxicity, digoxin toxicity can also cause hyperkalemia; inappropriate potassium administration could worsen cardiac conduction disturbances.
B
Atropine can be used for symptomatic bradycardia, but in digoxin toxicity the priority is to withhold the offending drug and notify the provider; atropine does not address the underlying toxicity and is not the first action.
C — correct
The patient exhibits classic signs of digoxin toxicity (nausea, visual disturbances, bradycardia, PVCs). The nurse should hold the next dose and promptly notify the provider for further evaluation, including a serum digoxin level and electrolyte assessment.
D
Transcutaneous pacing is reserved for severe, hemodynamically unstable bradycardia unresponsive to other measures. This patient has a stable blood pressure (110/70 mm Hg), so pacing is not the immediate priority.
TakeawayIn suspected digoxin toxicity, the first nursing action is to withhold the drug and notify the healthcare provider to obtain a serum digoxin level and guide specific therapy.
Medical nursing · medium
A nurse is caring for a patient who is receiving a unit of packed red blood cells. Fifteen minutes after the start of the infusion, the patient develops chills, fever, and flank pain. The nurse notes dark urine in the patient's urinary catheter bag. Which action should the nurse take first?
ASlow the transfusion and administer acetaminophen as prescribed.
BStop the transfusion and infuse 0.9% sodium chloride through new IV tubing.
CCollect a urine specimen to test for hemoglobinuria.
DNotify the healthcare provider of the patient's symptoms.
Show the answer and why the others fail
Answer: B. Stop the transfusion and infuse 0.9% sodium chloride through new IV tubing.
A
Slowing the transfusion does not stop the hemolytic reaction; acetaminophen may mask fever but does not address the underlying cause. The transfusion must be stopped immediately.
B — correct
The patient's symptoms (chills, fever, flank pain, dark urine) suggest an acute hemolytic transfusion reaction. The priority is to stop the transfusion to prevent further hemolysis and to maintain IV access with normal saline to support renal perfusion and prevent acute kidney injury.
C
Urine testing is part of the workup for a suspected transfusion reaction, but it is not the immediate priority. The transfusion must be stopped first to prevent further harm.
D
The provider must be notified, but this is not the first action. The nurse must first stop the transfusion and maintain IV access to stabilize the patient.
TakeawayIn a suspected acute hemolytic transfusion reaction, the nurse's first action is to stop the transfusion and maintain IV access with normal saline to prevent further hemolysis and protect renal function.
Medical nursing · medium
A 55‑year‑old woman is brought to the emergency department with a 2‑day history of fever, productive cough, and shortness of breath. On arrival her temperature is 38.9°C, pulse 112/min, respirations 22/min, blood pressure 100/62 mmHg, and oxygen saturation 91% on room air. Laboratory studies reveal a white blood cell count of 15,000/µL and a serum lactate of 2.3 mmol/L. The triage nurse suspects sepsis secondary to community‑acquired pneumonia. Which nursing action should be performed first?
AObtain two sets of blood cultures from separate peripheral sites before starting antibiotics.
BBegin a rapid 30 mL/kg isotonic crystalloid infusion to correct presumed hypovolemia.
CAdminister empiric broad‑spectrum intravenous antibiotics within the first hour.
DInsert a Foley catheter to monitor urine output for assessment of renal perfusion.
Show the answer and why the others fail
Answer: A. Obtain two sets of blood cultures from separate peripheral sites before starting antibiotics.
A — correct
Correct – Current Surviving Sepsis Guidelines state that acquiring blood cultures before antimicrobial therapy is the initial step, provided it does not cause a significant delay in antibiotic administration.
B
Incorrect – Fluid resuscitation is essential in septic shock, but this patient is not hypotensive enough to meet shock criteria; cultures should precede fluids.
C
Incorrect – Early antibiotics are critical, yet they must follow blood culture collection; giving them first would reduce diagnostic yield.
D
Incorrect – Urine output monitoring is useful later for evaluating response to therapy, but it is not the first priority when sepsis is suspected.
TakeawayIn suspected sepsis, obtain blood cultures before administering antibiotics, ensuring timely therapy is not delayed.
Medical nursing · medium
A 68‑year‑old man with a history of systolic heart failure comes to the emergency department because of worsening shortness of breath, orthopnea, and bilateral crackles. His pulse is 102/min, blood pressure 138/78 mmHg, and SpO₂ is 84% on room air. He is alert and able to speak in full sentences. Which nursing action should be performed first?
AApply supplemental oxygen and raise the head of the bed to a semi‑Fowler's position.
BObtain a stat arterial blood gas sample before any other intervention.
CAdminister a rapid IV push of furosemide 40 mg as ordered by the provider.
DPlace the patient in a supine position to facilitate cardiac preload assessment.
Show the answer and why the others fail
Answer: A. Apply supplemental oxygen and raise the head of the bed to a semi‑Fowler's position.
A — correct
Ensuring adequate oxygenation and reducing preload are the highest priorities in acute pulmonary edema.
B
ABG results are useful but delaying oxygen therapy can jeopardize the patient’s airway and breathing.
C
Diuretics are important for fluid removal but should follow establishing adequate oxygenation.
D
Supine positioning increases venous return and can worsen pulmonary edema; it is not appropriate as an initial step.
TakeawayIn acute decompensated heart failure, the first nursing priority is to improve oxygenation by giving supplemental O₂ and positioning the patient upright.
Medical nursing · medium
A 58‑year‑old man is brought to the emergency department complaining of crushing substernal chest pain that began 30 minutes ago and is radiating to his left arm. He is sweating, nauseated, and his blood pressure is 140/85 mmHg with a heart rate of 96/min. An ECG shows ST‑segment elevation in leads II, III, and aVF. While the cardiac catheterization team is being activated, what is the most appropriate nursing action for this patient?
AAdminister a sublingual nitroglycerin tablet to relieve pain
BGive the patient a chewable 325‑mg aspirin tablet immediately
CObtain a set of blood cultures before any medication is given
DStart an intravenous heparin infusion as soon as possible
Show the answer and why the others fail
Answer: B. Give the patient a chewable 325‑mg aspirin tablet immediately
A
Nitroglycerin can lower blood pressure and should be given after aspirin; the priority is antiplatelet therapy.
B — correct
Aspirin irreversibly inhibits platelet aggregation, reduces mortality in STEMI, and should be given as the first medication.
C
Blood cultures are not indicated for acute STEMI and would delay essential therapy.
D
Heparin is important but is administered after aspirin; starting it first delays the evidence‑based initial therapy.
TakeawayIn suspected STEMI, the first nursing intervention is immediate chewed aspirin to inhibit platelet aggregation.
Medical nursing · medium
A 72‑year‑old man with a history of systolic heart failure presents to the emergency department with a 2‑hour history of worsening shortness of breath, orthopnea, and bibasilar crackles. His pulse is 110/min, blood pressure 130/80 mmHg, and pulse oximetry reads 86% on room air. Which nursing intervention should be performed first?
AAdminister supplemental oxygen via a non‑rebreather mask.
BObtain a stat chest radiograph.
CInitiate intravenous furosemide therapy as prescribed.
DPlace the patient in a semi‑Fowler position and encourage sitting up.
Show the answer and why the others fail
Answer: A. Administer supplemental oxygen via a non‑rebreather mask.
A — correct
The patient is hypoxemic (SpO₂ 86%). Restoring adequate oxygenation is the priority before other measures such as diuretics, positioning, or imaging.
B
A chest X‑ray is useful for diagnosis, yet it can wait until the patient’s oxygenation is stabilized.
C
Loop diuretics reduce preload and improve pulmonary congestion, but they do not correct the immediate hypoxemia; oxygen should be given first.
D
Upright positioning helps improve ventilation, but it does not address the critical low oxygen saturation as promptly as supplemental oxygen.
TakeawayIn acute decompensated heart failure with hypoxemia, the first nursing action is to provide supplemental oxygen to improve tissue oxygen delivery.
Medical nursing · medium
A 58‑year‑old man arrives at the emergency department reporting crushing substernal chest pressure for 30 minutes that radiates to his left arm. He is diaphoretic, nauseous, and rates the pain as 8/10. His blood pressure is 138/84 mmHg, heart rate 96/min, respiratory rate 20/min, and oxygen saturation is 96% on room air. An ECG shows ST‑segment elevation in leads II, III, and aVF. Which nursing action should be performed first while preparing for definitive reperfusion therapy?
AGive a 0.4‑mg sublingual nitroglycerin dose.
BStart an IV morphine infusion for pain control.
CProvide a chewable 325‑mg aspirin tablet promptly.
DAdminister a high‑flow mask delivering 100% oxygen.
Show the answer and why the others fail
Answer: C. Provide a chewable 325‑mg aspirin tablet promptly.
A
Nitroglycerin helps relieve ischemic pain but should be administered after aspirin; it is not the first‑line action.
B
Morphine can mask ongoing ischemic pain and should be reserved until after antiplatelet therapy and reperfusion are initiated.
C — correct
Aspirin irreversibly inhibits platelet aggregation, reduces mortality, and is the highest‑priority medication in the early management of STEMI.
D
Oxygen is given only if saturation falls below 94%; routine high‑flow oxygen does not take priority over antiplatelet therapy.
TakeawayIn suspected STEMI, give chewable aspirin immediately; it is the first medication that improves survival before reperfusion.
Medical nursing · medium
A 58-year-old man is brought to the emergency department 45 minutes after the onset of crushing substernal chest pain radiating to his left arm. He is diaphoretic, rates 92/min, blood pressure 138/84 mmHg, and oxygen saturation is 96% on room air. An electrocardiogram shows ST‑segment elevation in leads II, III, and aVF. Which nursing action should be performed first?
AGive a chewable 325‑mg aspirin tablet and ensure it is swallowed completely
BApply a sublingual nitroglycerin tablet while monitoring blood pressure closely
CStart a morphine infusion to relieve pain and reduce myocardial oxygen demand
DPlace the patient in a semi‑Fowler position and administer supplemental oxygen
Show the answer and why the others fail
Answer: A. Give a chewable 325‑mg aspirin tablet and ensure it is swallowed completely
A — correct
Early aspirin inhibits platelet aggregation and improves mortality; it should be given before any other medication.
B
Nitroglycerin can be given after aspirin; giving it first may delay the life‑saving antiplatelet effect.
C
Morphine may mask ongoing ischemic changes and is not the first‑line intervention.
D
Oxygen is not indicated because his saturation is already adequate; priority is antiplatelet therapy.
TakeawayIn acute STEMI, the first nursing action is to give chewable aspirin promptly to reduce mortality.
Medical nursing · medium
A 68‑year‑old man is admitted from the emergency department with new‑onset atrial fibrillation. His heart rate is 150/min, irregularly irregular, blood pressure is 90/60 mmHg, and he has dyspnea with crackles at both lung bases. The electrocardiogram confirms atrial fibrillation with rapid ventricular response. Which nursing action should be performed first?
AAdminister an intravenous bolus of metoprolol to achieve rate control.
BObtain thyroid‑stimulating hormone (TSH) and free T4 levels to evaluate for hyperthyroidism.
CPrepare the patient and equipment for immediate synchronized cardioversion.
DStart an intravenous infusion of unfractionated heparin for anticoagulation.
Show the answer and why the others fail
Answer: C. Prepare the patient and equipment for immediate synchronized cardioversion.
A
Beta‑blockers may further lower blood pressure and worsen hemodynamic instability; they are not first‑line when the patient is hypotensive.
B
Thyroid testing is useful for identifying etiology, but it does not address the immediate life‑threatening instability.
C — correct
The patient is hemodynamically unstable (hypotension, pulmonary edema). The priority is to restore sinus rhythm quickly with synchronized cardioversion.
D
Anticoagulation is important but it is secondary to stabilizing the circulation; cardioversion should precede anticoagulation in unstable AF.
TakeawayHemodynamically unstable atrial fibrillation requires prompt synchronized cardioversion before rate control or anticoagulation.
Medical nursing · medium
A 62‑year‑old man is brought to the emergency department with sudden dyspnea, pleuritic chest pain, heart rate 128/min, blood pressure 85/60 mmHg, and SpO₂ 84% on room air. CT pulmonary angiography confirms a massive pulmonary embolism. Which nursing action should be performed first?
ABegin a continuous IV infusion of unfractionated heparin according to the hospital protocol.
BAdminister high‑flow supplemental oxygen via a non‑rebreather mask and attach continuous pulse‑oximetry monitoring.
CInsert a central venous catheter to allow administration of vasoactive medications if needed.
DInitiate intravenous tissue plasminogen activator (tPA) therapy as ordered for thrombolysis.
Show the answer and why the others fail
Answer: B. Administer high‑flow supplemental oxygen via a non‑rebreather mask and attach continuous pulse‑oximetry monitoring.
A
Heparin is essential for anticoagulation, but securing oxygenation and ventilation takes precedence over anticoagulant therapy in massive PE.
B — correct
The priority is to correct hypoxemia and maintain tissue oxygen delivery before other definitive treatments.
C
A central line may be required later for pressors, but it is not the immediate priority when the patient is hypoxic.
D
Thrombolysis is definitive for massive PE, but it should follow stabilization of airway and oxygenation; giving tPA first could delay lifesaving oxygen support.
TakeawayIn massive pulmonary embolism, the nurse’s first action is to ensure adequate oxygenation and monitor SpO₂ before initiating anticoagulant or thrombolytic therapy.
Medical nursing · medium
A 68‑year‑old man with a history of chronic congestive heart failure is admitted with worsening shortness of breath, an oxygen saturation of 86% on room air, bibasilar crackles, and 2+ pitting edema of the lower extremities. He reports a rapid weight gain of 4 kg over the past two days. Which nursing action should be performed first to address his acute pulmonary edema?
AObtain a stat 12‑lead ECG to evaluate for myocardial ischemia as the first step in management.
BAdminister a rapid infusion of 0.9% sodium chloride to correct presumed hypovolemia and improve perfusion.
CPlace the patient in a semi‑Fowler (30‑45°) position to reduce venous return and improve breathing.
DStart an intravenous dopamine infusion to increase cardiac output before any other measures are taken.
Show the answer and why the others fail
Answer: C. Place the patient in a semi‑Fowler (30‑45°) position to reduce venous return and improve breathing.
A
While an ECG is important, relieving the airway and breathing distress by positioning takes precedence in the ABC framework.
B
The patient is volume‑overloaded, not hypovolemic; giving isotonic fluid would worsen pulmonary edema.
C — correct
Elevating the head of the bed decreases preload and promotes lung expansion, making it the priority intervention in acute pulmonary edema.
D
Dopamine is a vasopressor used for hypotension; it does not address the immediate need for improved oxygenation and may increase afterload.
TakeawayIn acute heart‑failure‑related pulmonary edema, the first nursing priority is to position the patient semi‑Fowler to decrease preload and enhance breathing.
Medical nursing · medium
A 68‑year‑old man with a history of systolic heart failure arrives at the emergency department complaining of sudden shortness of breath and producing pink frothy sputum. On assessment he has bibasilar crackles, a respiratory rate of 28 breaths/min, and an oxygen saturation of 84% on room air. Which nursing action should be performed first?
AElevate the head of the bed to 45 degrees and encourage the patient to sit upright.
BAdminister the prescribed 40 mg IV dose of furosemide to promote diuresis.
CApply continuous cardiac monitoring and obtain a 12‑lead electrocardiogram.
DAdminister supplemental oxygen via a non‑rebreather mask at 15 L/min.
Show the answer and why the others fail
Answer: A. Elevate the head of the bed to 45 degrees and encourage the patient to sit upright.
A — correct
High‑Fowler positioning reduces venous return and pulmonary capillary pressure, immediately improving oxygenation in acute cardiogenic pulmonary edema; it is the first nursing intervention.
B
IV furosemide reduces preload and pulmonary congestion, but its diuretic effect requires several minutes; oxygenation and positioning must be established first.
C
Cardiac monitoring and ECG are essential for detecting arrhythmias, but the immediate threat is severe hypoxemia; airway and breathing take precedence over cardiac assessment.
D
Supplemental oxygen improves saturation, yet placing the patient upright is a faster, device‑independent method to improve ventilation‑perfusion matching and should be done before applying an oxygen mask.
TakeawayIn acute decompensated heart failure, the initial nursing priority is to place the patient in a high‑Fowler (45°) position to quickly improve oxygenation and reduce pulmonary congestion.
Medical nursing · medium
A 58‑year‑old man presents to the emergency department with sudden onset shortness of breath, sharp pleuritic chest pain, and a heart rate of 112/min. His oxygen saturation is 91% on room air. A bedside ECG shows sinus tachycardia, and a computed tomography pulmonary angiogram confirms a segmental pulmonary embolism. He is hemodynamically stable (blood pressure 122/78 mmHg) and has no contraindications to anticoagulation. Which medication should the nurse anticipate administering first as the initial therapeutic anticoagulant?
ASubcutaneous enoxaparin (low‑molecular‑weight heparin) at therapeutic dose
BOral warfarin 5 mg once daily
CIntravenous unfractionated heparin bolus followed by continuous infusion
DOral rivaroxaban 15 mg twice daily for 21 days
Show the answer and why the others fail
Answer: D. Oral rivaroxaban 15 mg twice daily for 21 days
A
LMWH provides rapid anticoagulation and is an acceptable option, but current guidelines give preference to a direct oral anticoagulant when rapid oral therapy is feasible, making LMWH no longer the preferred first choice in most stable patients.
B
Warfarin has a delayed onset of action and requires several days of overlapping parenteral anticoagulation before therapeutic effect is achieved; it is not used as the first‑line agent in acute PE.
C
UFH is reserved for patients who need immediate reversal, have severe renal impairment, or are undergoing invasive procedures; it is not the routine initial therapy for a stable PE with no contraindications.
D — correct
Guideline‑recommended initial therapy for a hemodynamically stable PE without contraindications is a direct oral anticoagulant such as rivaroxaban, which can be started immediately at 15 mg twice daily for 21 days without a parenteral lead‑in.
TakeawayIn a hemodynamically stable acute pulmonary embolism without contraindications, a direct oral anticoagulant (e.g., rivaroxaban) can be initiated as the first therapeutic anticoagulant; LMWH or UFH are alternatives but are not preferred first‑line agents per current guidelines.
Medical nursing · medium
A 58-year‑year-old man with small‑cell lung carcinoma is admitted because of increasing lethargy and nausea. Laboratory results show serum sodium 118 mEq/L, serum osmolality 260 mOsm/kg, urine osmolality 500 mOsm/kg, and urine sodium 45 mEq/L. His vital signs are stable. Which nursing intervention should be implemented first?
AAdminister a 3% hypertonic saline infusion intravenously over 30 minutes as prescribed.
BRestrict total fluid intake to 800 mL per day and monitor daily weight.
CEncourage the patient to drink at least 2 L of water each day.
DInitiate a loop diuretic such as furosemide to increase urinary sodium loss.
Show the answer and why the others fail
Answer: A. Administer a 3% hypertonic saline infusion intravenously over 30 minutes as prescribed.
A — correct
Guidelines recommend 3% hypertonic saline as the first‑line therapy for severe symptomatic hyponatremia (e.g., lethargy, nausea) to raise serum sodium promptly and reduce cerebral edema.
B
Fluid restriction is appropriate for chronic, asymptomatic or mildly symptomatic hyponatremia, but this patient has severe hyponatremia with neurologic symptoms, so immediate correction with hypertonic saline takes priority.
C
Increasing free‑water intake would worsen hyponatremia and exacerbate neurologic symptoms; it is contraindicated in SIADH‑related hyponatremia.
D
Loop diuretics may be considered later if hyponatremia persists after hypertonic saline and fluid restriction, but they do not address the acute neurologic risk and are not the initial intervention.
TakeawayIn severe symptomatic hyponatremia (serum Na <120 mEq/L with neurologic signs), the priority is rapid correction with 3% hypertonic saline; fluid restriction and diuretics are adjuncts once the patient is stabilized.