, Question 1
A patient with acute decompensated heart failure receiving intravenous
furosemide has a serum potassium of 3.1 mEq/L and a digoxin level of 2.8
ng/mL. Which assessment finding most urgently indicates a need for
immediate intervention?
A. Heart rate of 58 beats/min with frequent premature ventricular
contractions
B. Blood pressure of 98/62 mm Hg with orthostatic dizziness
C. Serum creatinine increase from 1.0 to 1.4 mg/dL
D. Urine output of 40 mL/hr over the past 4 hours
Correct Answer: A - Heart rate of 58 beats/min with frequent
premature ventricular contractions
RATIONALE
Hypokalemia potentiates digoxin toxicity, and a digoxin level of 2.8
ng/mL is above therapeutic range, increasing risk for life-threatening
ventricular dysrhythmias. Bradycardia with PVCs reflects digoxin
toxicity exacerbated by hypokalemia and requires immediate
intervention. The other findings are concerning but less immediately
lethal.
Question 2
A nurse manager is assigning patient care on a medical-surgical unit. Which
task is most appropriate to delegate to a licensed practical nurse (LPN)?
A. Administering the first dose of intravenous antibiotics to a patient with
a new central line
B. Performing a sterile dressing change on a surgical incision
C. Assessing a patient with new-onset confusion and agitation
D. Teaching a patient about a new prescription for warfarin
Correct Answer: B - Performing a sterile dressing change on a
surgical incision
Page 2
, RATIONALE
LPNs can perform sterile dressing changes on stable wounds within
their scope. Administering first-dose IV antibiotics via a new central
line, assessing new-onset confusion, and patient teaching require the
assessment and critical judgment of an RN. Delegation must align
with the LPN's scope of practice and patient acuity.
Question 3
A patient with septic shock is receiving norepinephrine and vasopressin
infusions. Which combination of parameters best reflects adequate tissue
perfusion?
A. Mean arterial pressure 65 mm Hg and central venous oxygen
saturation 70%
B. Systolic blood pressure 90 mm Hg and urine output 20 mL/hr
C. Heart rate 110 beats/min and capillary refill <3 seconds
D. Central venous pressure 4 mm Hg and serum lactate 4 mmol/L
Correct Answer: A - Mean arterial pressure 65 mm Hg and
central venous oxygen saturation 70%
RATIONALE
A mean arterial pressure of at least 65 mm Hg and central venous
oxygen saturation above 70% indicate adequate perfusion pressure and
oxygen delivery in septic shock. Low CVP and elevated lactate
indicate hypoperfusion, while systolic pressure alone and oliguria do
not confirm adequate tissue perfusion.
Question 4
A patient receiving a blood transfusion develops fever, chills, and flank pain 15
minutes into the infusion. Which action should the nurse take first?
A. Administer acetaminophen as prescribed for the febrile reaction
B. Stop the transfusion and maintain intravenous access with normal
saline
Page 3
, C. Slow the transfusion rate and reassess vital signs in 15 minutes
D. Collect a urine specimen for hemoglobinuria before stopping the
transfusion
Correct Answer: B - Stop the transfusion and maintain
intravenous access with normal saline
RATIONALE
Fever, chills, and flank pain suggest an acute hemolytic transfusion
reaction, which requires immediate cessation of the transfusion and
maintenance of IV access with normal saline. Slowing the infusion or
administering antipyretics delays life-saving intervention. Urine
collection can occur after stopping the transfusion.
Question 5
A patient with major depressive disorder has been taking sertraline for 3
weeks. Which patient statement most urgently requires follow-up?
A. I have been having trouble sleeping through the night.
B. I feel a little more energetic, but I still feel sad.
C. I have been thinking about how everyone would be better off without
me.
D. I have had some nausea and diarrhea since starting the medication.
Correct Answer: C - I have been thinking about how everyone
would be better off without me.
RATIONALE
Emerging energy during antidepressant therapy increases suicide risk,
and passive suicidal ideation requires immediate assessment and
intervention. Insomnia, residual sadness, and GI side effects are
common and important but do not indicate imminent danger. The
nurse must prioritize safety.
Page 4
A patient with acute decompensated heart failure receiving intravenous
furosemide has a serum potassium of 3.1 mEq/L and a digoxin level of 2.8
ng/mL. Which assessment finding most urgently indicates a need for
immediate intervention?
A. Heart rate of 58 beats/min with frequent premature ventricular
contractions
B. Blood pressure of 98/62 mm Hg with orthostatic dizziness
C. Serum creatinine increase from 1.0 to 1.4 mg/dL
D. Urine output of 40 mL/hr over the past 4 hours
Correct Answer: A - Heart rate of 58 beats/min with frequent
premature ventricular contractions
RATIONALE
Hypokalemia potentiates digoxin toxicity, and a digoxin level of 2.8
ng/mL is above therapeutic range, increasing risk for life-threatening
ventricular dysrhythmias. Bradycardia with PVCs reflects digoxin
toxicity exacerbated by hypokalemia and requires immediate
intervention. The other findings are concerning but less immediately
lethal.
Question 2
A nurse manager is assigning patient care on a medical-surgical unit. Which
task is most appropriate to delegate to a licensed practical nurse (LPN)?
A. Administering the first dose of intravenous antibiotics to a patient with
a new central line
B. Performing a sterile dressing change on a surgical incision
C. Assessing a patient with new-onset confusion and agitation
D. Teaching a patient about a new prescription for warfarin
Correct Answer: B - Performing a sterile dressing change on a
surgical incision
Page 2
, RATIONALE
LPNs can perform sterile dressing changes on stable wounds within
their scope. Administering first-dose IV antibiotics via a new central
line, assessing new-onset confusion, and patient teaching require the
assessment and critical judgment of an RN. Delegation must align
with the LPN's scope of practice and patient acuity.
Question 3
A patient with septic shock is receiving norepinephrine and vasopressin
infusions. Which combination of parameters best reflects adequate tissue
perfusion?
A. Mean arterial pressure 65 mm Hg and central venous oxygen
saturation 70%
B. Systolic blood pressure 90 mm Hg and urine output 20 mL/hr
C. Heart rate 110 beats/min and capillary refill <3 seconds
D. Central venous pressure 4 mm Hg and serum lactate 4 mmol/L
Correct Answer: A - Mean arterial pressure 65 mm Hg and
central venous oxygen saturation 70%
RATIONALE
A mean arterial pressure of at least 65 mm Hg and central venous
oxygen saturation above 70% indicate adequate perfusion pressure and
oxygen delivery in septic shock. Low CVP and elevated lactate
indicate hypoperfusion, while systolic pressure alone and oliguria do
not confirm adequate tissue perfusion.
Question 4
A patient receiving a blood transfusion develops fever, chills, and flank pain 15
minutes into the infusion. Which action should the nurse take first?
A. Administer acetaminophen as prescribed for the febrile reaction
B. Stop the transfusion and maintain intravenous access with normal
saline
Page 3
, C. Slow the transfusion rate and reassess vital signs in 15 minutes
D. Collect a urine specimen for hemoglobinuria before stopping the
transfusion
Correct Answer: B - Stop the transfusion and maintain
intravenous access with normal saline
RATIONALE
Fever, chills, and flank pain suggest an acute hemolytic transfusion
reaction, which requires immediate cessation of the transfusion and
maintenance of IV access with normal saline. Slowing the infusion or
administering antipyretics delays life-saving intervention. Urine
collection can occur after stopping the transfusion.
Question 5
A patient with major depressive disorder has been taking sertraline for 3
weeks. Which patient statement most urgently requires follow-up?
A. I have been having trouble sleeping through the night.
B. I feel a little more energetic, but I still feel sad.
C. I have been thinking about how everyone would be better off without
me.
D. I have had some nausea and diarrhea since starting the medication.
Correct Answer: C - I have been thinking about how everyone
would be better off without me.
RATIONALE
Emerging energy during antidepressant therapy increases suicide risk,
and passive suicidal ideation requires immediate assessment and
intervention. Insomnia, residual sadness, and GI side effects are
common and important but do not indicate imminent danger. The
nurse must prioritize safety.
Page 4
