, Question 1
A patient receiving continuous heparin infusion has an aPTT of 98 seconds
(therapeutic range 60-80 seconds) and new hematuria. Which action should the
nurse anticipate implementing first?
A. Administer vitamin K 10 mg IV push
B. Stop the heparin infusion and prepare to administer protamine sulfate
C. Continue the infusion and recheck aPTT in 4 hours
D. Transfuse fresh frozen plasma and maintain the infusion
Correct Answer: B - Stop the heparin infusion and prepare to
administer protamine sulfate
RATIONALE
An aPTT of 98 seconds with bleeding indicates supratherapeutic
heparin anticoagulation; the priority is to stop the infusion and
administer the antidote protamine sulfate. Vitamin K reverses
warfarin, not heparin; continuing the infusion risks hemorrhage; FFP
is not first-line for heparin reversal.
Question 2
A patient with major depressive disorder is started on sertraline. Which
statement by the patient indicates a need for further teaching?
A. "I should report any worsening mood or suicidal thoughts
immediately."
B. "I can stop the medication once I feel better."
C. "It may take several weeks before I notice improvement."
D. "I should avoid alcohol while taking this medication."
Correct Answer: B - "I can stop the medication once I feel
better."
Page 2
, RATIONALE
SSRIs must be tapered gradually; abrupt discontinuation can cause
discontinuation syndrome and relapse. Reporting worsening mood,
understanding delayed onset, and avoiding alcohol are correct. Option
B reflects a common misconception requiring correction.
Question 3
A nurse is evaluating a community health program aimed at reducing
hypertension. Which outcome measure best reflects the program's effectiveness
at the population level?
A. Percentage of participants who attended all education sessions
B. Mean systolic blood pressure reduction among participants at 6
months
C. Number of educational pamphlets distributed
D. Participant satisfaction scores with the program
Correct Answer: B - Mean systolic blood pressure reduction
among participants at 6 months
RATIONALE
Population-level effectiveness is best measured by clinical outcomes
such as blood pressure reduction, not process measures like
attendance, distribution counts, or satisfaction. Option B directly
reflects improved health status.
Question 4
A patient with type 1 diabetes has a blood glucose of 42 mg/dL and is
unresponsive. After establishing unresponsiveness, which action should the
nurse take next?
A. Administer 15 g oral glucose gel
B. Administer glucagon 1 mg IM
C. Start an IV and administer regular insulin
Page 3
, D. Recheck blood glucose in 15 minutes
Correct Answer: B - Administer glucagon 1 mg IM
RATIONALE
For severe hypoglycemia with unresponsiveness, IM glucagon is the
immediate intervention when IV access is unavailable. Oral glucose is
unsafe in an unresponsive patient; insulin would worsen
hypoglycemia; rechecking delays treatment.
Question 5
A nurse is caring for a client with a new colostomy. Which finding requires
immediate intervention?
A. Stoma is beefy red and moist
B. Stoma is dusky and cyanotic
C. Small amount of serosanguineous drainage on the dressing
D. Client reports passing flatus through the colostomy
Correct Answer: B - Stoma is dusky and cyanotic
RATIONALE
A dusky or cyanotic stoma indicates compromised perfusion and
possible necrosis, requiring immediate evaluation. A beefy red, moist
stoma is normal; serosanguineous drainage is expected initially;
passing flatus indicates return of bowel function.
Question 6
A nurse manager is reviewing staffing for the next shift. Which task is
appropriate to delegate to a nursing assistant (UAP)?
A. Administering a PRN analgesic to a postoperative client
B. Reinforcing teaching about a new medication with a client
C. Measuring and recording intake and output for a client with heart
failure
D. Assessing a client's incision for signs of infection
Page 4
A patient receiving continuous heparin infusion has an aPTT of 98 seconds
(therapeutic range 60-80 seconds) and new hematuria. Which action should the
nurse anticipate implementing first?
A. Administer vitamin K 10 mg IV push
B. Stop the heparin infusion and prepare to administer protamine sulfate
C. Continue the infusion and recheck aPTT in 4 hours
D. Transfuse fresh frozen plasma and maintain the infusion
Correct Answer: B - Stop the heparin infusion and prepare to
administer protamine sulfate
RATIONALE
An aPTT of 98 seconds with bleeding indicates supratherapeutic
heparin anticoagulation; the priority is to stop the infusion and
administer the antidote protamine sulfate. Vitamin K reverses
warfarin, not heparin; continuing the infusion risks hemorrhage; FFP
is not first-line for heparin reversal.
Question 2
A patient with major depressive disorder is started on sertraline. Which
statement by the patient indicates a need for further teaching?
A. "I should report any worsening mood or suicidal thoughts
immediately."
B. "I can stop the medication once I feel better."
C. "It may take several weeks before I notice improvement."
D. "I should avoid alcohol while taking this medication."
Correct Answer: B - "I can stop the medication once I feel
better."
Page 2
, RATIONALE
SSRIs must be tapered gradually; abrupt discontinuation can cause
discontinuation syndrome and relapse. Reporting worsening mood,
understanding delayed onset, and avoiding alcohol are correct. Option
B reflects a common misconception requiring correction.
Question 3
A nurse is evaluating a community health program aimed at reducing
hypertension. Which outcome measure best reflects the program's effectiveness
at the population level?
A. Percentage of participants who attended all education sessions
B. Mean systolic blood pressure reduction among participants at 6
months
C. Number of educational pamphlets distributed
D. Participant satisfaction scores with the program
Correct Answer: B - Mean systolic blood pressure reduction
among participants at 6 months
RATIONALE
Population-level effectiveness is best measured by clinical outcomes
such as blood pressure reduction, not process measures like
attendance, distribution counts, or satisfaction. Option B directly
reflects improved health status.
Question 4
A patient with type 1 diabetes has a blood glucose of 42 mg/dL and is
unresponsive. After establishing unresponsiveness, which action should the
nurse take next?
A. Administer 15 g oral glucose gel
B. Administer glucagon 1 mg IM
C. Start an IV and administer regular insulin
Page 3
, D. Recheck blood glucose in 15 minutes
Correct Answer: B - Administer glucagon 1 mg IM
RATIONALE
For severe hypoglycemia with unresponsiveness, IM glucagon is the
immediate intervention when IV access is unavailable. Oral glucose is
unsafe in an unresponsive patient; insulin would worsen
hypoglycemia; rechecking delays treatment.
Question 5
A nurse is caring for a client with a new colostomy. Which finding requires
immediate intervention?
A. Stoma is beefy red and moist
B. Stoma is dusky and cyanotic
C. Small amount of serosanguineous drainage on the dressing
D. Client reports passing flatus through the colostomy
Correct Answer: B - Stoma is dusky and cyanotic
RATIONALE
A dusky or cyanotic stoma indicates compromised perfusion and
possible necrosis, requiring immediate evaluation. A beefy red, moist
stoma is normal; serosanguineous drainage is expected initially;
passing flatus indicates return of bowel function.
Question 6
A nurse manager is reviewing staffing for the next shift. Which task is
appropriate to delegate to a nursing assistant (UAP)?
A. Administering a PRN analgesic to a postoperative client
B. Reinforcing teaching about a new medication with a client
C. Measuring and recording intake and output for a client with heart
failure
D. Assessing a client's incision for signs of infection
Page 4
