, Question 1
A patient with acute decompensated heart failure is prescribed IV furosemide.
Which assessment finding most urgently indicates a need to withhold the dose
and notify the provider?
A. Serum potassium of 3.2 mEq/L
B. Blood pressure of 92/58 mm Hg
C. Urine output of 40 mL/hr
D. Serum sodium of 134 mEq/L
Correct Answer: A - Serum potassium of 3.2 mEq/L
RATIONALE
Loop diuretics like furosemide can cause severe hypokalemia, which
increases the risk of digoxin toxicity and fatal dysrhythmias; a
potassium of 3.2 mEq/L is critically low and warrants withholding.
Blood pressure of 92/58 may be acceptable if the patient is
asymptomatic, and urine output and sodium are within expected
ranges.
Question 2
Which arterial blood gas value is most consistent with a diagnosis of metabolic
alkalosis with partial respiratory compensation?
A. pH 7.48, PaCO2 30 mm Hg, HCO3- 24 mEq/L
B. pH 7.30, PaCO2 50 mm Hg, HCO3- 26 mEq/L
C. pH 7.50, PaCO2 48 mm Hg, HCO3- 32 mEq/L
D. pH 7.28, PaCO2 28 mm Hg, HCO3- 16 mEq/L
Correct Answer: C - pH 7.50, PaCO2 48 mm Hg, HCO3- 32
mEq/L
Page 2
, RATIONALE
Metabolic alkalosis is characterized by an elevated pH and elevated
bicarbonate; partial respiratory compensation involves hypoventilation
to retain CO2, raising PaCO2 above normal. Option A shows
respiratory alkalosis, B shows respiratory acidosis, and D shows
metabolic acidosis with respiratory compensation.
Question 3
A patient receiving continuous IV heparin for venous thromboembolism has an
aPTT of 95 seconds (therapeutic range 60-80 seconds). Which action should
the nurse take first?
A. Administer protamine sulfate IV push
B. Stop the heparin infusion and notify the provider
C. Decrease the infusion rate by 2 units/kg/hr
D. Recheck the aPTT in 6 hours
Correct Answer: B - Stop the heparin infusion and notify the
provider
RATIONALE
An aPTT of 95 seconds indicates supratherapeutic anticoagulation,
increasing bleeding risk; the nurse should stop the infusion
immediately and notify the provider. Protamine sulfate is the antidote
but is not given without a provider order, and simply decreasing the
rate or rechecking later delays necessary intervention.
Question 4
Which assessment finding in a patient with a new below-the-knee cast is most
indicative of acute compartment syndrome?
A. Capillary refill of 3 seconds in the toes
B. Pain that intensifies with passive dorsiflexion of the foot
C. Mild swelling at the cast edges
D. Report of itching under the cast
Page 3
, Correct Answer: B - Pain that intensifies with passive dorsiflexion
of the foot
RATIONALE
Pain with passive stretch of the muscles in the affected compartment is
an early and highly specific sign of compartment syndrome. Capillary
refill of 3 seconds is borderline but not definitive, and swelling and
itching are expected cast-related findings.
Question 5
A patient with type 1 diabetes is found unresponsive with a blood glucose of
42 mg/dL. After administering glucagon, which assessment finding best
indicates the medication has been effective?
A. Blood glucose of 78 mg/dL
B. Heart rate decrease from 120 to 90 beats/min
C. Return of gag reflex
D. Urine output of 50 mL/hr
Correct Answer: A - Blood glucose of 78 mg/dL
RATIONALE
Glucagon stimulates glycogenolysis to raise blood glucose; a rise to
78 mg/dL demonstrates therapeutic effect. Heart rate changes, gag
reflex, and urine output are not direct indicators of glucagon
effectiveness.
Question 6
A nurse is reviewing a medication prescription for a patient with a new
ileostomy. Which order should the nurse question?
A. Loperamide 4 mg PO after each loose stool
B. Omeprazole 20 mg PO daily
C. Potassium chloride 40 mEq PO daily
D. Polyethylene glycol 17 g PO daily
Page 4
A patient with acute decompensated heart failure is prescribed IV furosemide.
Which assessment finding most urgently indicates a need to withhold the dose
and notify the provider?
A. Serum potassium of 3.2 mEq/L
B. Blood pressure of 92/58 mm Hg
C. Urine output of 40 mL/hr
D. Serum sodium of 134 mEq/L
Correct Answer: A - Serum potassium of 3.2 mEq/L
RATIONALE
Loop diuretics like furosemide can cause severe hypokalemia, which
increases the risk of digoxin toxicity and fatal dysrhythmias; a
potassium of 3.2 mEq/L is critically low and warrants withholding.
Blood pressure of 92/58 may be acceptable if the patient is
asymptomatic, and urine output and sodium are within expected
ranges.
Question 2
Which arterial blood gas value is most consistent with a diagnosis of metabolic
alkalosis with partial respiratory compensation?
A. pH 7.48, PaCO2 30 mm Hg, HCO3- 24 mEq/L
B. pH 7.30, PaCO2 50 mm Hg, HCO3- 26 mEq/L
C. pH 7.50, PaCO2 48 mm Hg, HCO3- 32 mEq/L
D. pH 7.28, PaCO2 28 mm Hg, HCO3- 16 mEq/L
Correct Answer: C - pH 7.50, PaCO2 48 mm Hg, HCO3- 32
mEq/L
Page 2
, RATIONALE
Metabolic alkalosis is characterized by an elevated pH and elevated
bicarbonate; partial respiratory compensation involves hypoventilation
to retain CO2, raising PaCO2 above normal. Option A shows
respiratory alkalosis, B shows respiratory acidosis, and D shows
metabolic acidosis with respiratory compensation.
Question 3
A patient receiving continuous IV heparin for venous thromboembolism has an
aPTT of 95 seconds (therapeutic range 60-80 seconds). Which action should
the nurse take first?
A. Administer protamine sulfate IV push
B. Stop the heparin infusion and notify the provider
C. Decrease the infusion rate by 2 units/kg/hr
D. Recheck the aPTT in 6 hours
Correct Answer: B - Stop the heparin infusion and notify the
provider
RATIONALE
An aPTT of 95 seconds indicates supratherapeutic anticoagulation,
increasing bleeding risk; the nurse should stop the infusion
immediately and notify the provider. Protamine sulfate is the antidote
but is not given without a provider order, and simply decreasing the
rate or rechecking later delays necessary intervention.
Question 4
Which assessment finding in a patient with a new below-the-knee cast is most
indicative of acute compartment syndrome?
A. Capillary refill of 3 seconds in the toes
B. Pain that intensifies with passive dorsiflexion of the foot
C. Mild swelling at the cast edges
D. Report of itching under the cast
Page 3
, Correct Answer: B - Pain that intensifies with passive dorsiflexion
of the foot
RATIONALE
Pain with passive stretch of the muscles in the affected compartment is
an early and highly specific sign of compartment syndrome. Capillary
refill of 3 seconds is borderline but not definitive, and swelling and
itching are expected cast-related findings.
Question 5
A patient with type 1 diabetes is found unresponsive with a blood glucose of
42 mg/dL. After administering glucagon, which assessment finding best
indicates the medication has been effective?
A. Blood glucose of 78 mg/dL
B. Heart rate decrease from 120 to 90 beats/min
C. Return of gag reflex
D. Urine output of 50 mL/hr
Correct Answer: A - Blood glucose of 78 mg/dL
RATIONALE
Glucagon stimulates glycogenolysis to raise blood glucose; a rise to
78 mg/dL demonstrates therapeutic effect. Heart rate changes, gag
reflex, and urine output are not direct indicators of glucagon
effectiveness.
Question 6
A nurse is reviewing a medication prescription for a patient with a new
ileostomy. Which order should the nurse question?
A. Loperamide 4 mg PO after each loose stool
B. Omeprazole 20 mg PO daily
C. Potassium chloride 40 mEq PO daily
D. Polyethylene glycol 17 g PO daily
Page 4
