, Question 1
A client with type 1 diabetes is admitted with a blood glucose of 612 mg/dL,
arterial pH 7.10, and deep, rapid respirations. Which set of findings best
confirms the underlying acid-base and compensatory status?
A. Metabolic acidosis with respiratory compensation; low serum
bicarbonate and low PaCO2
B. Metabolic acidosis without compensation; low serum bicarbonate and
elevated PaCO2
C. Respiratory alkalosis with metabolic compensation; elevated pH and
low PaCO2
D. Mixed respiratory and metabolic alkalosis; elevated bicarbonate and
elevated PaCO2
Correct Answer: A - Metabolic acidosis with respiratory
compensation; low serum bicarbonate and low PaCO2
RATIONALE
Diabetic ketoacidosis produces a primary metabolic acidosis (low
bicarbonate, low pH) and the deep, rapid Kussmaul respirations lower
PaCO2 as respiratory compensation. Option B describes an
uncompensated picture, C is the opposite primary disorder, and D is
incompatible with the low pH and low bicarbonate.
Question 2
A nurse must delegate tasks during a mass-casualty event. Which task is most
appropriate to delegate to unlicensed assistive personnel (UAP)?
A. Reassessing a client whose pain suddenly worsened after medication
B. Obtaining and recording vital signs on stable, ambulatory clients
C. Teaching a client how to use an incentive spirometer
D. Administering a PRN analgesic to a postoperative client
Correct Answer: B - Obtaining and recording vital signs on
stable, ambulatory clients
Page 2
, RATIONALE
UAP may perform and document routine vital signs on stable clients,
which falls within their scope and requires no nursing judgment.
Assessment/reassessment (A), client teaching (C), and medication
administration (D) are professional nursing responsibilities that cannot
be delegated to UAP.
Question 3
A client is prescribed heparin 18 units/kg/hr by continuous IV infusion. The
client weighs 165 lb and the pharmacy supplies heparin 25,000 units in 500 mL
D5W. What rate in mL/hr should the nurse set? (Round to the nearest whole
number.)
A. 27 mL/hr
B. 30 mL/hr
C. 54 mL/hr
D. 60 mL/hr
Correct Answer: A - 27 mL/hr
RATIONALE
Convert 165 lb to 75 kg; 18 units/kg/hr × 75 kg = 1,350 units/hr. The
concentration is 25,000 units/500 mL = 50 units/mL, so 1,350 ÷ 50 =
27 mL/hr. Options B, C, and D result from incorrect weight
conversion or concentration errors.
Question 4
A client with chronic kidney disease has a serum potassium of 6.8 mEq/L and
peaked T waves on the monitor. Which prescription should the nurse
implement first?
A. Administer sodium polystyrene sulfonate 15 g PO
B. Give calcium gluconate 10% IV as prescribed
C. Initiate a continuous insulin infusion with dextrose
Page 3
, D. Obtain a repeat serum potassium level
Correct Answer: B - Give calcium gluconate 10% IV as
prescribed
RATIONALE
Calcium gluconate is the immediate cardioprotective intervention for
hyperkalemia with ECG changes, stabilizing the myocardium while
other measures take effect. Sodium polystyrene and insulin/dextrose
lower potassium more slowly, and repeating the level delays
emergency treatment.
Question 5
A client at 36 weeks gestation reports a sudden gush of clear fluid and is
admitted for preterm premature rupture of membranes. Which assessment
finding is most concerning?
A. Fetal heart rate baseline of 140 beats/min with moderate variability
B. Maternal temperature of 100.8°F (38.2°C) with uterine tenderness
C. Nitrazine paper turning blue-green on specimen testing
D. Leakage of fluid that increases with coughing
Correct Answer: B - Maternal temperature of 100.8°F (38.2°C)
with uterine tenderness
RATIONALE
Fever with uterine tenderness after PPROM signals chorioamnionitis,
a serious infection requiring immediate intervention. A reassuring
fetal heart pattern, a positive nitrazine test, and fluid leakage with
increased abdominal pressure are expected findings in PPROM.
Question 6
A client with major depressive disorder is started on a selective serotonin
reuptake inhibitor. Which client statement indicates the most urgent need for
follow-up?
Page 4
A client with type 1 diabetes is admitted with a blood glucose of 612 mg/dL,
arterial pH 7.10, and deep, rapid respirations. Which set of findings best
confirms the underlying acid-base and compensatory status?
A. Metabolic acidosis with respiratory compensation; low serum
bicarbonate and low PaCO2
B. Metabolic acidosis without compensation; low serum bicarbonate and
elevated PaCO2
C. Respiratory alkalosis with metabolic compensation; elevated pH and
low PaCO2
D. Mixed respiratory and metabolic alkalosis; elevated bicarbonate and
elevated PaCO2
Correct Answer: A - Metabolic acidosis with respiratory
compensation; low serum bicarbonate and low PaCO2
RATIONALE
Diabetic ketoacidosis produces a primary metabolic acidosis (low
bicarbonate, low pH) and the deep, rapid Kussmaul respirations lower
PaCO2 as respiratory compensation. Option B describes an
uncompensated picture, C is the opposite primary disorder, and D is
incompatible with the low pH and low bicarbonate.
Question 2
A nurse must delegate tasks during a mass-casualty event. Which task is most
appropriate to delegate to unlicensed assistive personnel (UAP)?
A. Reassessing a client whose pain suddenly worsened after medication
B. Obtaining and recording vital signs on stable, ambulatory clients
C. Teaching a client how to use an incentive spirometer
D. Administering a PRN analgesic to a postoperative client
Correct Answer: B - Obtaining and recording vital signs on
stable, ambulatory clients
Page 2
, RATIONALE
UAP may perform and document routine vital signs on stable clients,
which falls within their scope and requires no nursing judgment.
Assessment/reassessment (A), client teaching (C), and medication
administration (D) are professional nursing responsibilities that cannot
be delegated to UAP.
Question 3
A client is prescribed heparin 18 units/kg/hr by continuous IV infusion. The
client weighs 165 lb and the pharmacy supplies heparin 25,000 units in 500 mL
D5W. What rate in mL/hr should the nurse set? (Round to the nearest whole
number.)
A. 27 mL/hr
B. 30 mL/hr
C. 54 mL/hr
D. 60 mL/hr
Correct Answer: A - 27 mL/hr
RATIONALE
Convert 165 lb to 75 kg; 18 units/kg/hr × 75 kg = 1,350 units/hr. The
concentration is 25,000 units/500 mL = 50 units/mL, so 1,350 ÷ 50 =
27 mL/hr. Options B, C, and D result from incorrect weight
conversion or concentration errors.
Question 4
A client with chronic kidney disease has a serum potassium of 6.8 mEq/L and
peaked T waves on the monitor. Which prescription should the nurse
implement first?
A. Administer sodium polystyrene sulfonate 15 g PO
B. Give calcium gluconate 10% IV as prescribed
C. Initiate a continuous insulin infusion with dextrose
Page 3
, D. Obtain a repeat serum potassium level
Correct Answer: B - Give calcium gluconate 10% IV as
prescribed
RATIONALE
Calcium gluconate is the immediate cardioprotective intervention for
hyperkalemia with ECG changes, stabilizing the myocardium while
other measures take effect. Sodium polystyrene and insulin/dextrose
lower potassium more slowly, and repeating the level delays
emergency treatment.
Question 5
A client at 36 weeks gestation reports a sudden gush of clear fluid and is
admitted for preterm premature rupture of membranes. Which assessment
finding is most concerning?
A. Fetal heart rate baseline of 140 beats/min with moderate variability
B. Maternal temperature of 100.8°F (38.2°C) with uterine tenderness
C. Nitrazine paper turning blue-green on specimen testing
D. Leakage of fluid that increases with coughing
Correct Answer: B - Maternal temperature of 100.8°F (38.2°C)
with uterine tenderness
RATIONALE
Fever with uterine tenderness after PPROM signals chorioamnionitis,
a serious infection requiring immediate intervention. A reassuring
fetal heart pattern, a positive nitrazine test, and fluid leakage with
increased abdominal pressure are expected findings in PPROM.
Question 6
A client with major depressive disorder is started on a selective serotonin
reuptake inhibitor. Which client statement indicates the most urgent need for
follow-up?
Page 4
