50-Item Situational Nursing Exam with Rationales (Expanded)

1. A patient with a BP of 88/50 mmHg becomes dizzy when standing. What should the nurse suspect?

A. Hypertension

B. Orthostatic hypotension

C. Normal BP

D. Stroke

Rationale: Orthostatic hypotension is common in older adults and causes dizziness upon standing due to a

drop in blood pressure.

2. After morphine administration, RR is 8 breaths/min. What is the priority action?

A. Document

B. Reassess later

C. Stimulate and assess SpO2

D. Lower bed

Rationale: Morphine can depress respiratory centers; stimulate the patient and assess oxygen levels

immediately.

3. A post-op patient has a temp of 38.8C. What should the nurse check first?

A. Surgical site

B. Diet

C. Activity

D. Mouth care

Rationale: A high fever post-op may indicate a surgical site infection.

4. A radial pulse is irregular. What should the nurse do next?

A. Record

B. Count for 15 sec

C. Auscultate apical pulse

D. Repeat radial

Rationale: An irregular radial pulse requires confirmation by auscultating the apical pulse for a full minute.

5. SpO2 is 86% on room air. What is the nurse's initial action?

A. High Fowler's + O2

B. Call MD

C. Encourage coughing
D. Suction

Rationale: Low oxygen saturation requires positioning and oxygen therapy before contacting the provider.

6. Heart sound: 'lub-dub-dub'. What is likely heard?

A. Normal

B. Murmur

C. S3 Gallop

D. Valve issue

Rationale: A third heart sound (S3) is heard as an extra 'dub' and may indicate fluid overload or heart failure.

7. Patient reports pain 8/10, but VS are normal. What should the nurse do?

A. Wait

B. Believe and document

C. Sedate

D. Delay meds

Rationale: Pain is a subjective experience; nurses should believe and document the patients report.

8. Blockage at right atrium affects which next structure?

A. Pulmonary artery

B. Right ventricle

C. Aorta

D. Left ventricle

Rationale: Blockage in the right atrium will affect the right ventricle next, as it receives blood from the atrium.

9. Patient has temp of 35.8C. What is likely happening?

A. Fever

B. Hypothermia

C. Hyperthermia

D. Sepsis

Rationale: A temperature below 36C suggests hypothermia.

10. Which VS finding is most concerning post-op?

A. RR 22

B. BP 110/70

C. SpO2 89%

D. Temp 37.6C

Rationale: SpO2 below 90% is critical and requires immediate attention.

A. Tachycardia

B. Bradycardia

C. Arrhythmia

D. Normal

Rationale: A heart rate below 60 bpm is termed bradycardia.

12. BP cuff too small can result in what?

A. Low reading

B. High reading

C. Accurate reading

D. No reading

Rationale: Using a cuff too small gives a falsely high blood pressure reading.

13. Child with RR of 38 breaths/min. What is the nurses action?

A. Reassure parent

B. Apply oxygen

C. Notify doctor

D. Check norms by age

Rationale: Always check age-specific normal values before acting on a pediatric vital sign.

14. Patient has bounding pulse. Likely cause?

A. Dehydration

B. Hypovolemia

C. Fever

D. Heart block

Rationale: A bounding pulse is often a sign of fever or high cardiac output.

15. Elderly patient has temp of 37.2C and chills. First action?

A. Give antipyretic

B. Remove blankets

C. Assess infection signs

D. Recheck in 1 hour

Rationale: Chills may signal the onset of infection; assess further before acting.

16. Infant HR is 160 bpm. What should the nurse do?

A. Call code
B. Recheck in 10 min

C. Recognize it's normal

D. Give IV fluids

Rationale: A heart rate of 160 bpm is normal for infants.

17. Post-exercise BP is 142/88. What is the best nursing comment?

A. BP is dangerously high

B. Normal response

C. Indicates hypertension

D. Needs medication

Rationale: Temporary rise in BP after exercise is expected.

18. Which organ controls body temperature?

A. Pituitary

B. Hypothalamus

C. Medulla

D. Brainstem

Rationale: The hypothalamus regulates body temperature.

19. A patient has SpO2 of 92%. What should the nurse do?

A. No action needed

B. Administer O2

C. Sit patient up

D. Notify provider

Rationale: Sitting the patient up helps improve oxygenation before applying supplemental O2.

20. Nurse detects crackles in lungs. What action is priority?

A. Lower bed

B. Start antibiotics

C. Notify provider

D. Give albuterol

Rationale: Crackles suggest fluid in lungs; notify the provider for evaluation.

21. Patient with RR 32 is anxious. What is the priority action?

A. Encourage deep breathing

B. Administer morphine

C. Recheck in 30 minutes
D. Call rapid response

Rationale: Calming measures like deep breathing can help with anxiety-induced hyperventilation.

22. Patient has irregular HR of 110 bpm. What is likely the cause?

A. Bradycardia

B. Normal sinus rhythm

C. Atrial fibrillation

D. Heart block

Rationale: Atrial fibrillation causes an irregularly irregular rhythm and can lead to HR of 110.

23. Patient has BP of 180/100. Which action is best?

A. Recheck in 5 min

B. Administer PRN antihypertensive

C. Notify provider

D. Ask about caffeine use

Rationale: High BP (180/100) requires prompt notification, not delayed monitoring.

24. Pulse deficit means what?

A. HR is too fast

B. Apical > radial

C. BP is low

D. Heart murmur

Rationale: A pulse deficit occurs when the apical rate exceeds the radial rate due to ineffective contractions.

25. Which structure controls breathing rhythm?

A. Hypothalamus

B. Cerebrum

C. Medulla oblongata

D. Pituitary gland

Rationale: The medulla oblongata controls respiratory rhythm.

26. Patient with COPD has RR of 10/min and is drowsy. What is the immediate concern?

A. Pain medication

B. CO retention

C. Hypoglycemia

D. Infection

Rationale: CO retention is common in COPD patients and can lead to CO narcosis, especially with
suppressed respiration.

27. A postoperative patient reports chest pain and dyspnea. Which vital sign supports pulmonary embolism?

A. HR 54

B. BP 130/80

C. RR 28

D. Temp 36.8C

Rationale: Tachypnea (RR 28) is a common early sign of pulmonary embolism.

28. Child with HR of 130 bpm and fever. What is the best action?

A. Give antibiotics

B. Apply warm compress

C. Offer fluids and monitor

D. Start CPR

Rationale: Mild tachycardia with fever in children often resolves with fluids and fever control.

29. Patient has BP 190/100, reports headache and blurry vision. What should the nurse do first?

A. Give pain meds

B. Monitor hourly

C. Notify provider

D. Offer water

Rationale: This may indicate a hypertensive crisis; prompt intervention is required.

30. Patient has cold, clammy skin and HR of 120. What condition is suspected?

A. Hypertension

B. Sepsis

C. Shock

D. Hypoxia

Rationale: Cold, clammy skin and tachycardia suggest decreased perfusion, likely shock.

31. Postpartum patient has HR 112, RR 24, and reports leg pain. What is the nurse's priority?

A. Assess for DVT

B. Encourage ambulation

C. Apply ice

D. Check fundus

Rationale: Tachycardia and leg pain postpartum suggest DVT risk; assess immediately.
32. Patient fainted after standing. BP is 110/70 supine and 85/55 standing. Whats this called?

A. Stable BP

B. Hypertensive crisis

C. Orthostatic hypotension

D. Vasovagal response

Rationale: A drop in BP with position change indicates orthostatic hypotension.

33. Teenager with HR 45 and no symptoms. What should the nurse do?

A. Panic

B. Reassess in 10 minutes

C. Check if athlete

D. Start atropine

Rationale: Well-conditioned athletes often have resting bradycardia without concern.

34. Patients temp is 39.5C. What vital sign change would you expect?

A. Bradycardia

B. Tachycardia

C. Hypotension

D. Slow RR

Rationale: High fever usually increases heart rate (tachycardia).

35. Patient with anemia has HR of 115 bpm. Why is this expected?

A. Blood volume overload

B. Compensatory mechanism

C. Dehydration

D. Hypoglycemia

Rationale: Tachycardia compensates for low oxygen-carrying capacity in anemia.

36. Elderly patient has SpO 90% but no distress. What should the nurse do?

A. Panic

B. Give oxygen

C. Document and continue monitoring

D. Suction

Rationale: SpO around 90% may be acceptable in older adults without distress.

37. Patient receiving blood transfusion has fever and chills. What should the nurse do first?

A. Give acetaminophen
B. Stop transfusion

C. Call lab

D. Lower bed

Rationale: Stop the transfusion immediatelythese are signs of a transfusion reaction.

38. Which vital sign is expected with pain?

A. Decreased BP

B. Slower pulse

C. Increased HR

D. Decreased RR

Rationale: Pain activates the sympathetic nervous system, increasing HR.

39. A patient has cool extremities and capillary refill >3 seconds. What should the nurse assess next?

A. O saturation

B. Temperature

C. Perfusion and BP

D. Blood glucose

Rationale: Slow cap refill and cool skin suggest poor perfusioncheck BP.

40. Patient with brain injury has rising BP and decreasing HR. What does this indicate?

A. Recovery

B. Cushing's triad

C. Infection

D. Hypoglycemia

Rationale: This is a sign of increased intracranial pressure (Cushings triad).

41. During sleep, a patients HR drops to 55 bpm. What should the nurse do?

A. Wake patient

B. Document finding

C. Call code

D. Give oxygen

Rationale: A lower heart rate during sleep can be normal.

42. A hypertensive patient is started on medication. What VS should be monitored closely?

A. Temp

B. Pulse

C. BP
D. Respiratory rate

Rationale: BP is directly affected by antihypertensive medications.

43. Patient with asthma has RR 30, using accessory muscles. What is the best action?

A. Encourage coughing

B. Administer bronchodilator

C. Suction

D. Call provider

Rationale: Wheezing and high RR indicate need for bronchodilator.

44. What VS pattern is seen in septic shock?

A. High temp, high HR, low BP

B. Low temp, low HR

C. Normal RR, low BP

D. High BP, low HR

Rationale: Fever, tachycardia, and hypotension are classic for sepsis.

45. Infant with fever has bulging fontanel. What does this suggest?

A. Dehydration

B. Infection and increased ICP

C. Hunger

D. Teething

Rationale: Bulging fontanel + fever = concern for meningitis/infection.

46. Anxiety can cause which VS change?

A. Hypotension

B. Bradycardia

C. Tachypnea

D. Hypothermia

Rationale: Anxiety activates the sympathetic system fast breathing.

47. Which organ responds first to sudden blood loss?

A. Liver

B. Kidneys

C. Brain

D. Heart

Rationale: The heart speeds up to maintain perfusion after blood loss.

A. Call doctor

B. Start CPR

C. Document as normal

D. Check glucose

Rationale: These are normal newborn vital signs.

49. Post-op patient reports pain and nausea. Which VS is important to check before meds?

A. Pulse

B. BP

C. Temp

D. RR

Rationale: RR is critical before giving opioids or sedatives.

50. Which VS change may indicate internal bleeding?

A. Increased HR, decreased BP

B. High temp

C. Low HR, high BP

D. Elevated SpO

Rationale: Tachycardia + hypotension = possible internal bleeding.