, 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. Stop the heparin infusion and prepare to administer protamine sulfate
C. Continue the infusion and recheck aPTT in 6 hours
D. Administer fresh frozen plasma and continue heparin at a reduced rate
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 infusion must be stopped and protamine
sulfate (the antidote) given. Vitamin K reverses warfarin, not heparin.
Continuing heparin or reducing the rate without stopping would
worsen bleeding risk. FFP is not first-line for heparin reversal.
Question 2
A laboring patient at 39 weeks gestation has a Category III fetal heart tracing
with recurrent late decelerations, minimal variability, and a baseline of 170
bpm. After initiating intrauterine resuscitation, which action should the nurse
take next?
A. Continue monitoring and reassess in 30 minutes
B. Prepare for an immediate cesarean birth
C. Administer a tocolytic to stop contractions
D. Perform a fetal scalp stimulation to assess acidemia
Correct Answer: B - Prepare for an immediate cesarean birth
Page 2
, RATIONALE
A Category III tracing with recurrent late decelerations and minimal
variability indicates fetal hypoxemia/acidemia and requires immediate
delivery, typically by cesarean. Continued monitoring or scalp
stimulation delays definitive management. Tocolytic therapy is not
indicated for Category III tracings.
Question 3
A patient with schizophrenia is prescribed clozapine. Which laboratory value
must be monitored weekly for the first 6 months of therapy to detect a
life-threatening adverse effect?
A. Serum sodium
B. Absolute neutrophil count
C. Liver function tests
D. Serum creatinine
Correct Answer: B - Absolute neutrophil count
RATIONALE
Clozapine carries a black box warning for severe
neutropenia/agranulocytosis; ANC must be monitored weekly for 6
months, then biweekly, then monthly. Sodium, LFTs, and creatinine
are not the primary monitoring parameters for clozapine's
life-threatening risk.
Question 4
A community health nurse is planning a primary prevention program for a
population with high rates of type 2 diabetes. Which intervention best
exemplifies primary prevention?
A. Screening all adults over 45 for hemoglobin A1c
B. Providing nutrition education and promoting physical activity in
schools
C. Referring newly diagnosed patients to a diabetes self-management
Page 3
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. Stop the heparin infusion and prepare to administer protamine sulfate
C. Continue the infusion and recheck aPTT in 6 hours
D. Administer fresh frozen plasma and continue heparin at a reduced rate
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 infusion must be stopped and protamine
sulfate (the antidote) given. Vitamin K reverses warfarin, not heparin.
Continuing heparin or reducing the rate without stopping would
worsen bleeding risk. FFP is not first-line for heparin reversal.
Question 2
A laboring patient at 39 weeks gestation has a Category III fetal heart tracing
with recurrent late decelerations, minimal variability, and a baseline of 170
bpm. After initiating intrauterine resuscitation, which action should the nurse
take next?
A. Continue monitoring and reassess in 30 minutes
B. Prepare for an immediate cesarean birth
C. Administer a tocolytic to stop contractions
D. Perform a fetal scalp stimulation to assess acidemia
Correct Answer: B - Prepare for an immediate cesarean birth
Page 2
, RATIONALE
A Category III tracing with recurrent late decelerations and minimal
variability indicates fetal hypoxemia/acidemia and requires immediate
delivery, typically by cesarean. Continued monitoring or scalp
stimulation delays definitive management. Tocolytic therapy is not
indicated for Category III tracings.
Question 3
A patient with schizophrenia is prescribed clozapine. Which laboratory value
must be monitored weekly for the first 6 months of therapy to detect a
life-threatening adverse effect?
A. Serum sodium
B. Absolute neutrophil count
C. Liver function tests
D. Serum creatinine
Correct Answer: B - Absolute neutrophil count
RATIONALE
Clozapine carries a black box warning for severe
neutropenia/agranulocytosis; ANC must be monitored weekly for 6
months, then biweekly, then monthly. Sodium, LFTs, and creatinine
are not the primary monitoring parameters for clozapine's
life-threatening risk.
Question 4
A community health nurse is planning a primary prevention program for a
population with high rates of type 2 diabetes. Which intervention best
exemplifies primary prevention?
A. Screening all adults over 45 for hemoglobin A1c
B. Providing nutrition education and promoting physical activity in
schools
C. Referring newly diagnosed patients to a diabetes self-management
Page 3
