, Question 1
A client with a new ileostomy has a stoma that is dark purple and dry, with no
output 12 hours postoperatively. Which action should the nurse take first?
A. Apply a heat pack to the stoma to stimulate circulation.
B. Notify the surgeon immediately of possible ischemia.
C. Document the findings as a normal postoperative variation.
D. Irrigate the stoma with warm saline to promote output.
Correct Answer: B - Notify the surgeon immediately of possible
ischemia.
RATIONALE
A dark purple, dry stoma with absent output indicates
ischemia/necrosis, requiring immediate surgical notification. Heat and
irrigation are contraindicated and may worsen tissue damage.
Documentation alone delays necessary intervention.
Question 2
Which prescription should the nurse question for a client receiving continuous
enteral feedings via a nasogastric tube?
A. Flush the tube with 30 mL water every 4 hours.
B. Check residual volume every 6 hours.
C. Administer crushed extended-release tablets through the tube.
D. Elevate the head of the bed to 30-45 degrees.
Correct Answer: C - Administer crushed extended-release tablets
through the tube.
RATIONALE
Crushed extended-release medications can cause tube occlusion and
unpredictable absorption, and should not be administered via enteral
tubes. Flushing, residual checks, and head elevation are standard safe
practices.
Page 2
, Question 3
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which
task is most appropriate to delegate?
A. Assessing a client's wound for signs of infection.
B. Administering a PRN analgesic to a postoperative client.
C. Measuring and recording a client's intake and output.
D. Teaching a client how to perform self-catheterization.
Correct Answer: C - Measuring and recording a client's intake
and output.
RATIONALE
Measuring and recording intake/output is a routine, non-invasive task
within UAP scope. Assessment, medication administration, and client
teaching require the clinical judgment of a licensed nurse and cannot
be delegated.
Question 4
A client with bipolar I disorder is in the acute manic phase and is pacing,
shouting, and throwing items. Which intervention should the nurse implement
first?
A. Administer PRN haloperidol as prescribed.
B. Place the client in a quiet, low-stimulation environment.
C. Apply restraints to prevent injury to self and others.
D. Initiate one-to-one observation and limit setting.
Correct Answer: B - Place the client in a quiet, low-stimulation
environment.
Page 3
, RATIONALE
The priority is safety and reducing environmental stimulation, which
can de-escalate manic behavior. Medication and restraints are
considered after less restrictive measures. One-to-one observation may
be used but is not the first intervention.
Question 5
The nurse is reviewing laboratory results for a client receiving heparin
infusion. Which finding requires immediate action?
A. aPTT of 45 seconds (control 30-40 seconds).
B. Platelet count of 150,000/mm³.
C. Hemoglobin of 13 g/dL.
D. aPTT of 90 seconds (control 30-40 seconds).
Correct Answer: D - aPTT of 90 seconds (control 30-40 seconds).
RATIONALE
An aPTT of 90 seconds is significantly prolonged, indicating
increased bleeding risk and possible heparin overdose. The nurse
should hold the infusion and notify the provider. The other values are
within normal limits.
Question 6
A client with chronic kidney disease has a serum potassium of 6.8 mEq/L.
Which prescribed intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate orally.
B. Prepare for emergency hemodialysis.
C. Administer intravenous calcium gluconate.
D. Give intravenous regular insulin with dextrose.
Correct Answer: C - Administer intravenous calcium gluconate.
Page 4
A client with a new ileostomy has a stoma that is dark purple and dry, with no
output 12 hours postoperatively. Which action should the nurse take first?
A. Apply a heat pack to the stoma to stimulate circulation.
B. Notify the surgeon immediately of possible ischemia.
C. Document the findings as a normal postoperative variation.
D. Irrigate the stoma with warm saline to promote output.
Correct Answer: B - Notify the surgeon immediately of possible
ischemia.
RATIONALE
A dark purple, dry stoma with absent output indicates
ischemia/necrosis, requiring immediate surgical notification. Heat and
irrigation are contraindicated and may worsen tissue damage.
Documentation alone delays necessary intervention.
Question 2
Which prescription should the nurse question for a client receiving continuous
enteral feedings via a nasogastric tube?
A. Flush the tube with 30 mL water every 4 hours.
B. Check residual volume every 6 hours.
C. Administer crushed extended-release tablets through the tube.
D. Elevate the head of the bed to 30-45 degrees.
Correct Answer: C - Administer crushed extended-release tablets
through the tube.
RATIONALE
Crushed extended-release medications can cause tube occlusion and
unpredictable absorption, and should not be administered via enteral
tubes. Flushing, residual checks, and head elevation are standard safe
practices.
Page 2
, Question 3
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which
task is most appropriate to delegate?
A. Assessing a client's wound for signs of infection.
B. Administering a PRN analgesic to a postoperative client.
C. Measuring and recording a client's intake and output.
D. Teaching a client how to perform self-catheterization.
Correct Answer: C - Measuring and recording a client's intake
and output.
RATIONALE
Measuring and recording intake/output is a routine, non-invasive task
within UAP scope. Assessment, medication administration, and client
teaching require the clinical judgment of a licensed nurse and cannot
be delegated.
Question 4
A client with bipolar I disorder is in the acute manic phase and is pacing,
shouting, and throwing items. Which intervention should the nurse implement
first?
A. Administer PRN haloperidol as prescribed.
B. Place the client in a quiet, low-stimulation environment.
C. Apply restraints to prevent injury to self and others.
D. Initiate one-to-one observation and limit setting.
Correct Answer: B - Place the client in a quiet, low-stimulation
environment.
Page 3
, RATIONALE
The priority is safety and reducing environmental stimulation, which
can de-escalate manic behavior. Medication and restraints are
considered after less restrictive measures. One-to-one observation may
be used but is not the first intervention.
Question 5
The nurse is reviewing laboratory results for a client receiving heparin
infusion. Which finding requires immediate action?
A. aPTT of 45 seconds (control 30-40 seconds).
B. Platelet count of 150,000/mm³.
C. Hemoglobin of 13 g/dL.
D. aPTT of 90 seconds (control 30-40 seconds).
Correct Answer: D - aPTT of 90 seconds (control 30-40 seconds).
RATIONALE
An aPTT of 90 seconds is significantly prolonged, indicating
increased bleeding risk and possible heparin overdose. The nurse
should hold the infusion and notify the provider. The other values are
within normal limits.
Question 6
A client with chronic kidney disease has a serum potassium of 6.8 mEq/L.
Which prescribed intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate orally.
B. Prepare for emergency hemodialysis.
C. Administer intravenous calcium gluconate.
D. Give intravenous regular insulin with dextrose.
Correct Answer: C - Administer intravenous calcium gluconate.
Page 4
