, Question 1
A patient receiving continuous IV heparin for venous thromboembolism has an
aPTT of 98 seconds (therapeutic range 60-80 seconds) and new hematuria.
Which action should the nurse anticipate as the priority?
A. Administer vitamin K 10 mg IV push.
B. Hold the heparin infusion and prepare to administer protamine sulfate.
C. Continue the infusion and recheck the aPTT in 6 hours.
D. Transfuse fresh frozen plasma and restart heparin at a lower rate.
Correct Answer: B - Hold the heparin infusion and prepare to
administer protamine sulfate.
RATIONALE
An aPTT of 98 seconds with hematuria indicates supratherapeutic
heparin anticoagulation and bleeding; the infusion must be stopped
and protamine sulfate given as the antidote. Vitamin K reverses
warfarin, not heparin, and FFP is not first-line for heparin reversal.
Question 2
During a mass casualty triage, which patient should the nurse tag as red
(immediate) using the Simple Triage and Rapid Treatment (START)
algorithm?
A. A patient with a respiratory rate of 8/min after repositioning the
airway.
B. A patient with a respiratory rate of 34/min and capillary refill of 3
seconds.
C. A patient who is ambulatory with minor lacerations.
D. A patient with a respiratory rate of 22/min and a radial pulse present.
Correct Answer: B - A patient with a respiratory rate of 34/min
and capillary refill of 3 seconds.
Page 2
, RATIONALE
In START, a respiratory rate >30/min or capillary refill >2 seconds
classifies the patient as red (immediate) because intervention is needed
within minutes. A rate of 8/min after airway repositioning is expectant
(black), ambulatory patients are green, and a rate of 22/min with a
pulse is yellow (delayed).
Question 3
Which statement by a patient newly prescribed lithium carbonate indicates a
need for further teaching?
A. I will maintain a consistent sodium intake and drink 2-3 L of fluid
daily.
B. I will take the medication with food to reduce stomach upset.
C. I will stop taking lithium if I develop a fine hand tremor.
D. I will have my blood lithium level checked regularly.
Correct Answer: C - I will stop taking lithium if I develop a fine
hand tremor.
RATIONALE
A fine hand tremor is an expected early side effect of lithium and does
not require discontinuation; stopping the medication abruptly can
precipitate mania. Consistent sodium and fluid intake, taking with
food, and monitoring serum levels are all correct self-care measures.
Question 4
A patient with a chest tube following a thoracotomy has continuous bubbling
in the water-seal chamber. Which action should the nurse take first?
A. Clamp the chest tube near the insertion site.
B. Assess the insertion site and tubing for an air leak.
C. Increase the suction to -40 cm H2O.
D. Document the finding as normal.
Page 3
, Correct Answer: B - Assess the insertion site and tubing for an air
leak.
RATIONALE
Continuous bubbling in the water-seal chamber indicates an air leak;
the nurse should first assess the insertion site and tubing connections
to locate the source. Clamping the tube can cause tension
pneumothorax, and increasing suction or documenting as normal is
unsafe.
Question 5
A patient at 32 weeks gestation presents with painless, bright red vaginal
bleeding. Which assessment finding is most concerning for placental abruption
rather than placenta previa?
A. Uterine tenderness and a firm, board-like abdomen.
B. A soft, nontender uterus.
C. Bleeding that is painless and bright red.
D. A fundal height that is appropriate for gestational age.
Correct Answer: A - Uterine tenderness and a firm, board-like
abdomen.
RATIONALE
Placental abruption typically presents with painful vaginal bleeding,
uterine tenderness, and a firm, board-like abdomen due to
retroplacental bleeding. Placenta previa classically presents with
painless, bright red bleeding and a soft, nontender uterus.
Question 6
The nurse is calculating the dose of dopamine for a patient in cardiogenic
shock. The order is 5 mcg/kg/min for a patient weighing 70 kg. The available
concentration is 400 mg in 250 mL D5W. What is the infusion rate in mL/hr?
A. 13.1 mL/hr
Page 4
A patient receiving continuous IV heparin for venous thromboembolism has an
aPTT of 98 seconds (therapeutic range 60-80 seconds) and new hematuria.
Which action should the nurse anticipate as the priority?
A. Administer vitamin K 10 mg IV push.
B. Hold the heparin infusion and prepare to administer protamine sulfate.
C. Continue the infusion and recheck the aPTT in 6 hours.
D. Transfuse fresh frozen plasma and restart heparin at a lower rate.
Correct Answer: B - Hold the heparin infusion and prepare to
administer protamine sulfate.
RATIONALE
An aPTT of 98 seconds with hematuria indicates supratherapeutic
heparin anticoagulation and bleeding; the infusion must be stopped
and protamine sulfate given as the antidote. Vitamin K reverses
warfarin, not heparin, and FFP is not first-line for heparin reversal.
Question 2
During a mass casualty triage, which patient should the nurse tag as red
(immediate) using the Simple Triage and Rapid Treatment (START)
algorithm?
A. A patient with a respiratory rate of 8/min after repositioning the
airway.
B. A patient with a respiratory rate of 34/min and capillary refill of 3
seconds.
C. A patient who is ambulatory with minor lacerations.
D. A patient with a respiratory rate of 22/min and a radial pulse present.
Correct Answer: B - A patient with a respiratory rate of 34/min
and capillary refill of 3 seconds.
Page 2
, RATIONALE
In START, a respiratory rate >30/min or capillary refill >2 seconds
classifies the patient as red (immediate) because intervention is needed
within minutes. A rate of 8/min after airway repositioning is expectant
(black), ambulatory patients are green, and a rate of 22/min with a
pulse is yellow (delayed).
Question 3
Which statement by a patient newly prescribed lithium carbonate indicates a
need for further teaching?
A. I will maintain a consistent sodium intake and drink 2-3 L of fluid
daily.
B. I will take the medication with food to reduce stomach upset.
C. I will stop taking lithium if I develop a fine hand tremor.
D. I will have my blood lithium level checked regularly.
Correct Answer: C - I will stop taking lithium if I develop a fine
hand tremor.
RATIONALE
A fine hand tremor is an expected early side effect of lithium and does
not require discontinuation; stopping the medication abruptly can
precipitate mania. Consistent sodium and fluid intake, taking with
food, and monitoring serum levels are all correct self-care measures.
Question 4
A patient with a chest tube following a thoracotomy has continuous bubbling
in the water-seal chamber. Which action should the nurse take first?
A. Clamp the chest tube near the insertion site.
B. Assess the insertion site and tubing for an air leak.
C. Increase the suction to -40 cm H2O.
D. Document the finding as normal.
Page 3
, Correct Answer: B - Assess the insertion site and tubing for an air
leak.
RATIONALE
Continuous bubbling in the water-seal chamber indicates an air leak;
the nurse should first assess the insertion site and tubing connections
to locate the source. Clamping the tube can cause tension
pneumothorax, and increasing suction or documenting as normal is
unsafe.
Question 5
A patient at 32 weeks gestation presents with painless, bright red vaginal
bleeding. Which assessment finding is most concerning for placental abruption
rather than placenta previa?
A. Uterine tenderness and a firm, board-like abdomen.
B. A soft, nontender uterus.
C. Bleeding that is painless and bright red.
D. A fundal height that is appropriate for gestational age.
Correct Answer: A - Uterine tenderness and a firm, board-like
abdomen.
RATIONALE
Placental abruption typically presents with painful vaginal bleeding,
uterine tenderness, and a firm, board-like abdomen due to
retroplacental bleeding. Placenta previa classically presents with
painless, bright red bleeding and a soft, nontender uterus.
Question 6
The nurse is calculating the dose of dopamine for a patient in cardiogenic
shock. The order is 5 mcg/kg/min for a patient weighing 70 kg. The available
concentration is 400 mg in 250 mL D5W. What is the infusion rate in mL/hr?
A. 13.1 mL/hr
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