14 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 14 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?
ARestrict oral fluids and monitor hourly blood glucose only
BAdminister a subcutaneous rapid-acting insulin sliding scale dose
CBegin isotonic intravenous fluid resuscitation
DAdminister intravenous sodium bicarbonate
Show the answer and why the others fail
Answer: C. Begin isotonic intravenous fluid resuscitation
A
Fluid restriction worsens the underlying hypovolemia and hyperosmolality; monitoring alone does not treat the emergency.
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 — 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.
D
There is no significant acidosis (pH 7.36) and bicarbonate is not indicated; this picture is hyperosmolar hyperglycemic state, not ketoacidosis.
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?
ATarget an oxygen saturation of 98 to 100 percent with a simple face mask
BTitrate controlled oxygen to a target saturation of 88 to 92 percent
CWithhold oxygen to avoid suppressing the hypoxic respiratory drive
DApply a non-rebreather mask at 15 L/min
Show the answer and why the others fail
Answer: B. Titrate controlled oxygen to a target saturation of 88 to 92 percent
A
Overshooting saturation in COPD increases the risk of worsening hypercapnia and acidosis, and confers no benefit.
B — 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.
C
Withholding oxygen from a hypoxemic patient is dangerous. Hypoxia kills faster than hypercapnia; oxygen is given, but titrated.
D
High-flow uncontrolled oxygen in a chronically hypercapnic patient can worsen CO2 retention through ventilation-perfusion mismatch and the Haldane effect.
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?
AUncompensated respiratory acidosis
BMetabolic alkalosis with respiratory compensation
CPartially compensated respiratory acidosis
DFully compensated respiratory acidosis
Show the answer and why the others fail
Answer: C. Partially compensated respiratory acidosis
A
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.
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 — 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.
D
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.
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?
AHold metformin only if the patient's blood glucose is below 70 mg/dL.
BHold the metformin before the scan and for 48 hours after the procedure.
CAdminister the metformin as scheduled before the scan.
DAdminister metformin with a high-carbohydrate meal just before the scan.
Show the answer and why the others fail
Answer: C. Administer the metformin as scheduled before the scan.
A
The decision to withhold metformin is based on renal function and risk of lactic acidosis, not on current blood glucose levels.
B
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.
C — 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.
D
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.
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 regular insulin and dextrose.
BAdminister oral sodium zirconium cyclosilicate.
CPrepare the patient for emergency hemodialysis.
DAdminister intravenous calcium gluconate.
Show the answer and why the others fail
Answer: D. Administer intravenous calcium gluconate.
A
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.
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
Hemodialysis effectively removes potassium, but preparation takes time. Calcium must be given first to protect the heart while dialysis is arranged.
D — 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.
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?
AAdminister neomycin as prescribed
BInitiate a fluid restriction of 1.5 L/day
CAdminister the prescribed lactulose
DRestrict dietary protein to 20 g/day
Show the answer and why the others fail
Answer: C. Administer the prescribed lactulose
A
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.
B
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.
C — 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.
D
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.
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?
AAspirin 325 mg chewed
BNitroglycerin sublingual
CMorphine sulfate IV
DIbuprofen 600 mg orally
Show the answer and why the others fail
Answer: D. Ibuprofen 600 mg orally
A
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.
B
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.
C
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.
D — correct
Ibuprofen is a first-line NSAID for acute pericarditis, providing anti-inflammatory and analgesic effects. The dose is appropriate for treating pericarditis.
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 inhaled albuterol
BAdminister intravenous methylprednisolone
CAdminister inhaled fluticasone
DObtain a portable chest x-ray
Show the answer and why the others fail
Answer: A. Administer inhaled albuterol
A — 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.
B
Systemic corticosteroids reduce airway inflammation but have a delayed onset of action (hours) and are not the immediate next step after oxygen.
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?
AFebuxostat
BIndomethacin
CAllopurinol
DColchicine
Show the answer and why the others fail
Answer: D. Colchicine
A
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.
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
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.
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?
ADiphenhydramine 50 mg IV
BEpinephrine 0.3 mg IM
C0.9% sodium chloride 500 mL IV bolus
DAlbuterol 2.5 mg via nebulizer
Show the answer and why the others fail
Answer: B. Epinephrine 0.3 mg IM
A
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.
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
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.
D
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.
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
BInitiate continuous heparin infusion
CAdminister aspirin 300 mg orally
DRefer for urgent carotid endarterectomy
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
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.
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
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.
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.
BHold the digoxin and notify the healthcare provider.
CAdminister atropine 0.5 mg IV push.
DPrepare the patient for transcutaneous pacing.
Show the answer and why the others fail
Answer: B. 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 — 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.
C
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.
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?
ANotify the healthcare provider of the patient's symptoms.
BStop the transfusion and infuse 0.9% sodium chloride through new IV tubing.
CSlow the transfusion and administer acetaminophen as prescribed.
DCollect a urine specimen to test for hemoglobinuria.
Show the answer and why the others fail
Answer: B. Stop the transfusion and infuse 0.9% sodium chloride through new IV tubing.
A
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.
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
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.
D
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.
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.