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A nurse in the emergency department is assessing four clients. Which client should the nurse see first?
A) A 45-year-old male with sharp chest pain that worsens with deep inspiration
B) A 22-year-old female with nausea, vomiting, and right lower quadrant pain
C) A 60-year-old female with slurred speech and facial droop that began 3 hours ago
D) A 34-year-old male with a swollen ankle and a pain rating of 8/10

C – Signs of a stroke (slurred speech, facial droop) require immediate evaluation for possible thrombolytic therapy.

A client with atrial fibrillation is prescribed warfarin. Which statement by the client indicates a need for further teaching?
A) "I will have my INR checked regularly."
B) "I will eat a consistent amount of leafy greens."
C) "I can take aspirin if I have a headache."
D) "I should report any unusual bruising or bleeding."

C – Aspirin increases bleeding risk when taken with warfarin.

A nurse is assessing a client at 36 weeks gestation who reports a headache and blurred vision. Which finding is most concerning?
A) 1+ protein in urine
B) Blood pressure of 160/100 mmHg
C) Mild dependent edema in the legs
D) Fundal height measuring at 36 cm

B – High BP + headache/blurred vision suggests severe preeclampsia, which can lead to eclampsia (seizures).

The nurse is caring for a 4-year-old child who has epiglottitis. Which intervention is most appropriate?
A) Obtain a throat culture to confirm the diagnosis
B) Keep the child calm and avoid inspecting the throat
C) Administer oral fluids to prevent dehydration
D) Place the child in a supine position for comfort

B – Do NOT inspect throat; it could cause complete airway obstruction.

A client with schizophrenia tells the nurse, "The voices are telling me to hurt myself." What is the best response by the nurse?
A) "Ignore the voices. They aren't real."
B) "I don't hear any voices, but I understand that you do."
C) "You should focus on something else when you hear voices."
D) "Why do you think the voices are telling you that?"

B – Acknowledge their experience but do not validate hallucinations. Ensure safety.

A client with COPD is receiving oxygen at 4 L/min via nasal cannula. The client becomes drowsy and has a decreased respiratory rate. What is the nurse’s priority action?
A) Increase the oxygen flow rate to 6 L/min
B) Lower the oxygen flow rate
C) Encourage the client to take deep breaths
D) Place the client in high Fowler’s position

B – Lowering O₂ helps prevent CO₂ retention in COPD clients.

A pregnant woman at 34 weeks gestation is diagnosed with preeclampsia. Which assessment finding would indicate a worsening condition?

A) Blood pressure of 140/90 mmHg

B) Mild swelling of the ankles

C) Deep tendon reflexes +4 and clonus present

D) 1+ protein in the urine

C – Hyperreflexia (+4 DTRs & clonus) indicates worsening preeclampsia and risk for seizures.

A nurse is reviewing a fetal heart rate (FHR) strip. Which of the following requires immediate intervention?

A) Moderate variability with accelerations

B) Early decelerations

C) Late decelerations

D) Variable decelerations that resolve with position changes

C – Late decelerations are a sign of uteroplacental insufficiency and require intervention.

A woman in active labor suddenly states, “I feel like I need to push!” The nurse notes that the cervix is 8 cm dilated. What is the best action?

A) Encourage the client to start pushing

B) Tell the client to take deep breaths and pant through contractions

C) Call the provider for immediate delivery

D) Increase IV fluids

B – The client should pant to prevent pushing until fully dilated to avoid cervical tearing.

A nurse is caring for a postpartum client who delivered 2 hours ago. Which finding requires immediate intervention?

A) Fundus firm at the midline, slightly above the umbilicus

B) Moderate lochia rubra with small clots

C) Saturation of one perineal pad in 15 minutes

D) Uterine cramping relieved with ibuprofen

C – Heavy bleeding (1 pad in 15 min) is a sign of postpartum hemorrhage.

A newborn is assessed at 1 minute with the following findings:

• Heart rate: 90 bpm

• Slow, irregular breathing

• Some flexion of extremities

• Grimaces when suctioned

• Pink body, blue extremities

What is this newborn’s APGAR score?
A) 3
B) 5
C) 7
D) 9

B – The APGAR score is 5 (1 point each for HR, breathing, muscle tone, reflex, and color).

A nurse is assessing a client at a 6-week postpartum visit. Which statement suggests postpartum depression rather than normal "baby blues"?
A) "I cry sometimes, but I feel better when I get some rest."
B) "I feel overwhelmed, but my partner helps a lot."
C) "I can't sleep, even when the baby is sleeping, and I don't feel connected to my baby."
D) "I feel more emotional than usual, but I think it’s getting better each day."

C – Inability to sleep, feeling disconnected, and lack of bonding are signs of postpartum depression.