, Question 1
A client with heart failure is prescribed IV furosemide. Which set of
assessment findings best indicates the need to hold the dose and notify the
provider?
A. Potassium 3.1 mEq/L, blood pressure 88/54 mm Hg, and new-onset
confusion
B. Potassium 4.2 mEq/L, blood pressure 118/72 mm Hg, and urine output
60 mL/hr
C. Sodium 138 mEq/L, heart rate 92/min, and bilateral crackles at bases
D. Magnesium 1.8 mg/dL, respiratory rate 18/min, and 1+ pedal edema
Correct Answer: A - Potassium 3.1 mEq/L, blood pressure 88/54
mm Hg, and new-onset confusion
RATIONALE
Furosemide is a loop diuretic that depletes potassium and can cause
hypotension; hypokalemia, hypotension, and altered mental status
signal hypoperfusion and arrhythmia risk, requiring the dose to be
held. The other options show normal or expected findings (stable
potassium, adequate urine output, expected crackles/edema) that do
not mandate holding the dose.
Question 2
A laboring client at 38 weeks gestation has a reassuring fetal heart rate pattern.
After artificial rupture of membranes, clear fluid is noted. Which nursing
action is the priority immediately following the procedure?
A. Assess the fetal heart rate for 1 full minute
B. Document the color and amount of fluid
C. Change the client's perineal pad
D. Encourage the client to ambulate
Correct Answer: A - Assess the fetal heart rate for 1 full minute
Page 2
, RATIONALE
The priority after amniotomy is to assess the fetal heart rate to detect
cord prolapse or compression, which can occur suddenly after
membrane rupture. Documentation, perineal care, and ambulation are
important but not the immediate priority; ambulation may even be
contraindicated if cord prolapse is suspected.
Question 3
A client with major depressive disorder is started on phenelzine. Which dietary
selection indicates the client understands the teaching?
A. Grilled chicken with steamed broccoli and a glass of milk
B. Pepperoni pizza with a side of sauerkraut
C. Aged cheddar cheese and a glass of red wine
D. Soy sauce-marinated beef with draft beer
Correct Answer: A - Grilled chicken with steamed broccoli and a
glass of milk
RATIONALE
Phenelzine is an MAOI; clients must avoid tyramine-rich foods (aged
cheese, cured meats, sauerkraut, soy sauce, draft beer, red wine) to
prevent hypertensive crisis. Grilled chicken, broccoli, and milk are
low in tyramine and safe. The other options contain high-tyramine
items.
Question 4
A community health nurse is planning a primary prevention program for a
population at risk for type 2 diabetes. Which intervention is most appropriate?
A. Screen all adults with a fasting blood glucose test
B. Provide a community walking group and nutrition education
C. Offer free HbA1c testing at a health fair
D. Refer newly diagnosed clients to a diabetes educator
Correct Answer: B - Provide a community walking group and
Page 3
, nutrition education
RATIONALE
Primary prevention aims to prevent disease before it occurs; lifestyle
interventions such as exercise and nutrition education are primary
prevention. Screening (fasting glucose, HbA1c) is secondary
prevention, and referral for education after diagnosis is tertiary
prevention.
Question 5
A nurse manager is evaluating staffing effectiveness. Which outcome best
indicates effective delegation to unlicensed assistive personnel (UAP)?
A. UAP reports a client's new-onset chest pain to the nurse immediately
B. UAP performs a sterile dressing change independently
C. UAP administers oral medications to stable clients
D. UAP adjusts the IV infusion rate based on intake/output
Correct Answer: A - UAP reports a client's new-onset chest pain
to the nurse immediately
RATIONALE
UAP can monitor and report changes but cannot perform sterile
procedures, administer medications, or adjust IV rates-those require a
licensed nurse. Prompt reporting of chest pain demonstrates
appropriate delegation and supervision. The other options represent
tasks outside UAP scope.
Question 6
A client is admitted with severe preeclampsia and is receiving magnesium
sulfate IV. Which finding is the earliest indicator of magnesium toxicity?
A. Loss of deep tendon reflexes
B. Respiratory rate of 10/min
C. Serum magnesium level of 8 mg/dL
Page 4
A client with heart failure is prescribed IV furosemide. Which set of
assessment findings best indicates the need to hold the dose and notify the
provider?
A. Potassium 3.1 mEq/L, blood pressure 88/54 mm Hg, and new-onset
confusion
B. Potassium 4.2 mEq/L, blood pressure 118/72 mm Hg, and urine output
60 mL/hr
C. Sodium 138 mEq/L, heart rate 92/min, and bilateral crackles at bases
D. Magnesium 1.8 mg/dL, respiratory rate 18/min, and 1+ pedal edema
Correct Answer: A - Potassium 3.1 mEq/L, blood pressure 88/54
mm Hg, and new-onset confusion
RATIONALE
Furosemide is a loop diuretic that depletes potassium and can cause
hypotension; hypokalemia, hypotension, and altered mental status
signal hypoperfusion and arrhythmia risk, requiring the dose to be
held. The other options show normal or expected findings (stable
potassium, adequate urine output, expected crackles/edema) that do
not mandate holding the dose.
Question 2
A laboring client at 38 weeks gestation has a reassuring fetal heart rate pattern.
After artificial rupture of membranes, clear fluid is noted. Which nursing
action is the priority immediately following the procedure?
A. Assess the fetal heart rate for 1 full minute
B. Document the color and amount of fluid
C. Change the client's perineal pad
D. Encourage the client to ambulate
Correct Answer: A - Assess the fetal heart rate for 1 full minute
Page 2
, RATIONALE
The priority after amniotomy is to assess the fetal heart rate to detect
cord prolapse or compression, which can occur suddenly after
membrane rupture. Documentation, perineal care, and ambulation are
important but not the immediate priority; ambulation may even be
contraindicated if cord prolapse is suspected.
Question 3
A client with major depressive disorder is started on phenelzine. Which dietary
selection indicates the client understands the teaching?
A. Grilled chicken with steamed broccoli and a glass of milk
B. Pepperoni pizza with a side of sauerkraut
C. Aged cheddar cheese and a glass of red wine
D. Soy sauce-marinated beef with draft beer
Correct Answer: A - Grilled chicken with steamed broccoli and a
glass of milk
RATIONALE
Phenelzine is an MAOI; clients must avoid tyramine-rich foods (aged
cheese, cured meats, sauerkraut, soy sauce, draft beer, red wine) to
prevent hypertensive crisis. Grilled chicken, broccoli, and milk are
low in tyramine and safe. The other options contain high-tyramine
items.
Question 4
A community health nurse is planning a primary prevention program for a
population at risk for type 2 diabetes. Which intervention is most appropriate?
A. Screen all adults with a fasting blood glucose test
B. Provide a community walking group and nutrition education
C. Offer free HbA1c testing at a health fair
D. Refer newly diagnosed clients to a diabetes educator
Correct Answer: B - Provide a community walking group and
Page 3
, nutrition education
RATIONALE
Primary prevention aims to prevent disease before it occurs; lifestyle
interventions such as exercise and nutrition education are primary
prevention. Screening (fasting glucose, HbA1c) is secondary
prevention, and referral for education after diagnosis is tertiary
prevention.
Question 5
A nurse manager is evaluating staffing effectiveness. Which outcome best
indicates effective delegation to unlicensed assistive personnel (UAP)?
A. UAP reports a client's new-onset chest pain to the nurse immediately
B. UAP performs a sterile dressing change independently
C. UAP administers oral medications to stable clients
D. UAP adjusts the IV infusion rate based on intake/output
Correct Answer: A - UAP reports a client's new-onset chest pain
to the nurse immediately
RATIONALE
UAP can monitor and report changes but cannot perform sterile
procedures, administer medications, or adjust IV rates-those require a
licensed nurse. Prompt reporting of chest pain demonstrates
appropriate delegation and supervision. The other options represent
tasks outside UAP scope.
Question 6
A client is admitted with severe preeclampsia and is receiving magnesium
sulfate IV. Which finding is the earliest indicator of magnesium toxicity?
A. Loss of deep tendon reflexes
B. Respiratory rate of 10/min
C. Serum magnesium level of 8 mg/dL
Page 4
