A. A patient with traumatic brain injury shows bradycardia, hypertension, and irregular respirations. ICP monitor shows 48 mmHg. What is the immediate nursing action?

B. A patient after craniotomy develops sudden severe headache, unequal pupils, and vomiting. ICP monitor shows 50 mmHg. What is the nurse’s immediate action?

C. A patient with Addison’s disease presents with BP 70/38 mmHg, Na⁺ 116 mEq/L, and K⁺ 7.3 mEq/L. What is the immediate nursing intervention?

D. A patient with acute pancreatitis presents with severe abdominal pain, hypotension, and Grey Turner’s sign. What is the priority nursing action?

E. A patient with a crush injury develops dark tea-colored urine, CK 20,000 U/L, and rising creatinine. What is the immediate nursing intervention?

F. A charge nurse must assign duties. Which task is most appropriate for a nursing assistant?

G. A patient with seizure history develops sudden agitation, confusion, and fluctuating attention without tonic–clonic movements. What is the likely condition?

H. A patient with necrotizing pancreatitis presents with septic shock and intra-abdominal hypertension. What is the immediate nursing action?

I. A patient with untreated hyperthyroidism presents with fever 40°C, tachycardia 160 bpm, agitation, and diaphoresis. What is the immediate nursing intervention?

J. A patient with advanced cancer states, “I do not want resuscitation if my heart stops.” What should the nurse do first?

K. A patient with long-standing hypothyroidism is admitted with hypothermia, bradycardia, hypotension, and altered mental status. What is the immediate nursing intervention?

L. A patient with multiple fractures develops severe leg pain unrelieved by opioids, pallor, paresthesia, and tense swelling. What is the nurse’s immediate action?

M. A patient with chronic kidney disease has K⁺ 7.2 mEq/L, peaked T waves, and wide QRS complexes. What is the priority nursing action?

N. A patient with seizure disorder develops continuous tonic–clonic activity lasting >5 minutes without regaining consciousness. What is the priority nursing action?

O. A septic patient presents with fever, BP 76/40 mmHg, HR 138, and lactate 5 mmol/L. What is the immediate nursing intervention?

P. A patient with acute kidney injury has K⁺ 6.9 mEq/L, peaked T waves on ECG, and confusion. What is the immediate nursing action?

Q. A patient’s spouse says, “I don’t know how much longer I can take care of them at home.” What is the nurse’s best response?

R. A patient on mechanical ventilation suddenly develops hypotension, absent breath sounds on the right, and tracheal deviation to the left. What is the immediate nursing action?

S. A patient with septic shock on norepinephrine has urine output <10 mL/hr, lactate 7 mmol/L, and refractory acidosis. What is the next nursing action?

T. A patient on mechanical ventilation shows high peak pressures, hypoxemia, and absent breath sounds on the left. What is the immediate nursing action?

U. A patient with acute kidney injury develops pH 7.10, HCO₃⁻ 12 mEq/L, K⁺ 6.7 mEq/L, and Kussmaul respirations. What is the priority nursing action?

V. A patient with acute kidney injury develops severe hyperkalemia (K⁺ 7.4 mEq/L) and ventricular tachycardia. What is the immediate nursing intervention?

W. A postoperative patient suddenly develops chest pain, tachypnea, dyspnea, and SpO₂ 78% despite oxygen. What is the nurse’s immediate action?

X. A patient with cirrhosis develops massive hematemesis. Despite octreotide, bleeding persists. BP 76/40 mmHg, HR 128 bpm. What is the next nursing action?

Y. A nurse feels uncomfortable with a physician’s repeated rude behavior toward staff. What is the most appropriate action?

Z. A patient with chronic kidney disease presents with K⁺ 6.8 mEq/L, peaked T waves, and confusion. What is the immediate intervention?

AA. A patient with pneumonia suddenly develops pleuritic chest pain, dyspnea, tachycardia, and SpO₂ 80% on oxygen. What is the next nursing action?

AB. A patient with Graves’ disease develops fever 40°C, tachycardia 160 bpm, and agitation. What is the immediate nursing intervention?

AC. A trauma patient with multiple fractures suddenly develops confusion, dyspnea, and petechiae over the chest. SpO₂ is 74% despite oxygen therapy. What is the immediate action?

AD. An ICU patient suddenly develops acute agitation, disorientation, and hallucinations. Vitals are stable, no focal neuro deficits. What is the most appropriate initial nursing intervention?

AE. A patient with pericarditis develops jugular venous distension, muffled heart sounds, and hypotension. What is the immediate nursing action?

AF. A patient with cirrhosis develops confusion, asterixis, and ammonia 110 µmol/L. What is the priority nursing intervention?

AG. A patient with dilated cardiomyopathy presents with dyspnea, pulmonary edema, and BP 78/46 mmHg. What is the priority nursing action?

AH. A patient with history of epilepsy becomes unresponsive with continuous seizure activity lasting 10 minutes. What is the nurse’s priority action?

AI. A nurse witnesses a provider about to start a central line insertion without verifying consent. What is the priority nursing action?

AJ. A patient in the ICU develops acute confusion, agitation, and fluctuating attention. Vitals stable, no focal neurological deficits. What is the most appropriate intervention?

AK. A nurse witnesses a provider beginning a procedure on the wrong patient. What is the priority action?

AL. A nurse learns that a patient’s lab result indicating a critical potassium level was not reported to the provider. What is the nurse’s best action?

AM. A patient with Addison’s disease presents with BP 72/38 mmHg, Na⁺ 115 mEq/L, K⁺ 7.1 mEq/L, and severe weakness. What is the immediate nursing intervention?

AN. A patient with end-stage renal disease presents with confusion, pericardial rub, and hypotension. What should the nurse do next?

AO. A patient with cirrhosis presents with massive hematemesis. Octreotide has failed to control bleeding. BP 78/40 mmHg, HR 130 bpm. What is the next nursing intervention?

AP. A patient with acute decompensated heart failure presents with BP 86/50 mmHg, pulmonary edema, and cold extremities. What is the nurse’s immediate action?

AQ. A patient with small bowel obstruction has severe distension, bilious vomiting, and tachycardia. What is the priority nursing intervention?

AR. A patient with severe asthma exacerbation becomes drowsy. SpO₂ is 77% despite oxygen, and breath sounds are silent. What is the next nursing action?

AS. A nurse realizes they administered a medication one hour late and did not notify the provider. What is the nurse’s best action?

AT. A nurse is assigned to more patients than can be safely managed. What is the most appropriate action?

AU. A patient with multiple fractures develops tachypnea, hypoxemia, confusion, and petechiae on the chest. What is the priority nursing intervention?

AV. A dialysis patient develops chest pain, hypotension, and pericardial friction rub. What should the nurse do next?

AW. A patient with severe hypothyroidism presents with hypothermia, bradycardia, hypotension, and altered mental status. What is the immediate nursing action?

AX. A patient with multiple fractures reports sudden dyspnea, hypoxemia, and petechiae on the chest. SpO₂ 74% despite oxygen. What is the immediate nursing action?

AY. A patient with pneumonia develops fever, tachycardia, hypotension (BP 72/40 mmHg), and mottled skin despite fluids. What is the immediate nursing intervention?

AZ. A patient presents with severe abdominal distension, vomiting, and absent bowel movements for 4 days. Imaging shows dilated loops of bowel with air–fluid levels. What is the priority nursing action?

BA. A nurse is asked to assist with a procedure they have never performed before. What is the safest action?

BB. A patient asks the nurse to share personal details about their life to “build trust.” What is the best response?

BC. During bedside report, a nurse notices a colleague discussing another patient’s diagnosis within earshot of visitors. What is the most appropriate action?

BD. A trauma patient with prolonged limb compression develops dark red urine and CK 15,000 U/L. What is the immediate nursing action?

BE. A patient with a history of alcohol abuse presents with confusion, tremors, tachycardia, and hypertension 36 hours after last drink. What is the priority nursing intervention?

BF. A patient with trauma and prolonged immobilization develops dark tea-colored urine and CK 18,000 U/L. What is the immediate priority?

BG. A patient with sepsis remains hypotensive after 3 L of fluids. MAP 54 mmHg, lactate 6 mmol/L. What is the next nursing action?

BH. A patient with septic shock remains hypotensive after 30 mL/kg fluid resuscitation. MAP is 54 mmHg, lactate 5 mmol/L. What is the next nursing intervention?

BI. A patient with Addison’s disease presents with profound hypotension, Na⁺ 118 mEq/L, and K⁺ 7.2 mEq/L. What is the priority nursing intervention?

BJ. A patient’s spouse angrily says, “You aren’t doing enough to save my partner.” What is the nurse’s best response?

BK. A patient with acute pancreatitis has persistent abdominal distension, rising bladder pressures, and hypotension. What is the priority nursing intervention?

BL. A patient with hypertrophic cardiomyopathy collapses during exercise, presenting with syncope and systolic murmur at the left sternal border. What is the priority nursing intervention?

BM. A patient with aortic stenosis collapses during exertion, presenting with syncope, systolic murmur, and hypotension. What is the immediate nursing action?

BN. A nurse sees a coworker texting while preparing IV medications. What is the most appropriate action?

BO. A patient with long-standing hypothyroidism presents with hypothermia, bradycardia, hypotension, and altered mental status. What is the immediate nursing intervention?

BP. A patient after multiple bee stings develops hypotension, wheezing, and angioedema. What is the nurse’s immediate action?

BQ. A patient with acute pancreatitis develops severe abdominal distension, rising bladder pressure, and hypotension. What is the immediate nursing action?

BR. A patient with severe sepsis continues to deteriorate despite antibiotics and vasopressors. Lactate is 6 mmol/L, urine output <10 mL/hr. What is the next nursing priority?

BS. A patient with multiple fractures complains of severe leg pain out of proportion to injury, with paresthesia and pallor. What is the immediate nursing intervention?

BT. A patient with chronic kidney disease on dialysis presents with chest pain, pericardial friction rub, and hypotension. What is the nurse’s immediate action?

BU. During a rapid response, a provider requests a high-risk medication that seems inappropriate for the patient’s condition. What should the nurse do first?

BV. A patient after a long bone fracture develops severe leg pain unrelieved by opioids, pallor, paresthesia, and weak pulses. What is the next nursing action?

BW. A patient with sudden tearing chest pain radiating to the back has unequal blood pressures in the arms. What is the nurse’s immediate action?

BX. A patient with crush injury reports severe pain out of proportion to injury, pallor, paresthesia, and tense swelling of the leg. What is the next nursing action?

BY. A patient with diabetic ketoacidosis has K⁺ 5.9 mEq/L before insulin infusion begins. What is the immediate nursing intervention?

BZ. A patient with ARDS on mechanical ventilation has PaO₂ 42 mmHg despite FiO₂ 100% and PEEP 18 cmH₂O. Plateau pressure is 26 cmH₂O. What is the next nursing action?

CA. A patient with acute MI suddenly develops severe chest pain, hypotension, and a new loud systolic murmur at the apex. What is the nurse’s immediate action?

CB. A patient with Addison’s disease presents with severe hypotension, hyponatremia, and hyperkalemia. What is the nurse’s immediate action?

CC. A patient with multiple fractures develops confusion, dyspnea, and petechiae on the chest. SpO₂ 72% despite oxygen therapy. What is the immediate nursing action?

CD. A patient with Addison’s disease arrives with BP 72/40 mmHg, Na⁺ 116 mEq/L, and K⁺ 7.1 mEq/L. What is the immediate intervention?

CE. A patient with hypertensive emergency presents with BP 230/120 mmHg, headache, and visual changes. What is the immediate nursing intervention?

CF. A dialysis patient becomes confused, nauseated, and has headache within an hour after treatment. What is the nurse’s immediate action?

CG. A patient with severe pneumonia on mechanical ventilation shows PaO₂ 44 mmHg on FiO₂ 100% and PEEP 20 cmH₂O. Plateau pressure is 27 cmH₂O. What is the priority action?

CH. A patient with Marfan syndrome presents with acute chest pain radiating to the back, BP 70/40 mmHg, and pulse deficit in the left arm. What is the immediate action?

CI. A patient on hemodialysis develops severe headache, nausea, and confusion 1 hour after starting treatment. What is the priority nursing action?

CJ. A patient with traumatic brain injury develops continuous tonic–clonic activity lasting >5 minutes. What is the priority intervention?

CK. A nurse witnesses a provider starting a procedure without confirming patient identity. What is the priority nursing action?

CL. A mechanically ventilated patient suddenly shows SpO₂ 70%, high peak inspiratory pressures, and absent breath sounds on the left. What is the immediate action?

CM. A patient after a crush injury develops severe leg pain, pallor, paresthesia, and tense swelling. Distal pulses are weak. What is the immediate nursing action?

CN. A patient asks, “Why must I continue wearing oxygen if I feel fine?” What is the nurse’s best response?

CO. A patient with Graves’ disease develops hyperthermia, tachycardia, and agitation. What is the nurse’s immediate intervention?

CP. A patient becomes angry when told visiting hours are over and demands an exception. What is the nurse’s best action?

CQ. A young adult with type 1 diabetes presents with polyuria, Kussmaul respirations, and fruity breath odor. Labs: pH 7.15, glucose 480 mg/dL. What is the immediate nursing action?

CR. A patient with severe COPD exacerbation becomes somnolent. ABG: pH 7.22, PaCO₂ 78 mmHg, PaO₂ 52 mmHg on BiPAP. What is the next nursing action?

CS. A patient with traumatic brain injury presents with bradycardia, hypertension, and irregular respirations. ICP monitor shows 47 mmHg. What is the priority nursing action?

CT. A patient on hemodialysis develops confusion, nausea, and headache shortly after initiation of treatment. What is the priority nursing action?

CU. A patient tells the nurse, “I want to stop all treatments and go home.” What is the nurse’s best response?

CV. A patient with multiple trauma and crush injury develops dark brown urine and CK 12,000 U/L. What is the priority nursing action?

CW. A patient with acute STEMI develops chest pain, diaphoresis, and BP 78/46 mmHg. Crackles are present bilaterally. What is the nurse’s immediate action?

CX. A patient on high-flow oxygen for pneumonia suddenly develops sharp chest pain and absent breath sounds on the right. What is the next nursing action?

CY. A patient with blunt chest trauma develops muffled heart sounds, jugular venous distension, and hypotension. What is the immediate nursing action?

CZ. A patient with traumatic brain injury becomes increasingly drowsy, develops unequal pupils, and ICP rises to 50 mmHg. What is the immediate nursing action?

DA. A patient refuses a blood transfusion due to religious beliefs despite severe anemia. What is the nurse’s best action?

DB. A patient develops acute agitation, hallucinations, and disorientation following ICU admission. Vitals stable, no focal deficits. What is the most appropriate initial nursing intervention?

DC. A patient’s family is upset that visiting hours are restricted after surgery. What is the nurse’s best action?

DD. A patient with COPD exacerbation on BiPAP becomes lethargic. ABG: pH 7.19, PaCO₂ 85 mmHg, PaO₂ 50 mmHg. What is the next nursing action?

DE. A patient receiving high PEEP for ARDS suddenly develops tachycardia, hypotension, and tracheal deviation. What is the nurse’s immediate action?

DF. A patient with pericarditis develops pulsus paradoxus, hypotension, and jugular venous distension. What is the nurse’s immediate action?

DG. A nurse sees a coworker frequently cutting corners with infection control practices. What is the best nursing action?

DH. A patient with type 1 diabetes presents with glucose 520 mg/dL, fruity breath odor, and Kussmaul respirations. ABG: pH 7.18, HCO₃⁻ 12 mEq/L. What is the immediate nursing action?

DI. A charge nurse is making assignments. Which task is appropriate for a nursing assistant?

DJ. A patient with Addison’s disease presents with hypotension, confusion, Na⁺ 118 mEq/L, and K⁺ 7.0 mEq/L. What is the immediate intervention?

DK. A patient with end-stage renal disease presents with K⁺ 7.5 mEq/L, peaked T waves, and ventricular tachycardia. What is the immediate nursing action?

DL. A patient develops sudden hypotension, stridor, urticaria, and wheezing immediately after receiving IV antibiotics. What is the nurse’s immediate action?

DM. A trauma patient complains of excruciating leg pain unrelieved by opioids, paresthesia, pallor, and absent pulses. What is the immediate nursing action?

DN. A patient with septic shock remains hypotensive after 3 L of IV fluids. MAP 55 mmHg, lactate 6 mmol/L. What is the next nursing action?

DO. A patient with ARDS on mechanical ventilation has plateau pressures >30 cmH₂O despite low tidal volumes. PaO₂ remains <55 mmHg on FiO₂ 100%. What is the next nursing action?

DP. A family member asks detailed questions about another patient in the same room. What is the nurse’s most appropriate response?

DQ. A patient with long bone fracture develops sudden dyspnea, confusion, and petechiae over the chest. SpO₂ is 74% despite oxygen therapy. What is the priority action?

DR. A patient with type 1 diabetes presents with glucose 520 mg/dL, fruity breath odor, and Kussmaul respirations. ABG: pH 7.18, HCO₃⁻ 12 mEq/L. What is the immediate nursing action?

DS. A patient with chronic kidney disease presents with K⁺ 7.2 mEq/L and ventricular tachycardia on the monitor. What is the immediate intervention?

DT. A patient with acute pancreatitis presents with hypovolemia, severe abdominal pain, and Grey Turner’s sign. What is the immediate nursing intervention?

DU. A patient’s family insists on aggressive treatment that conflicts with the patient’s advance directive. What is the nurse’s best action?