, Question 1
A patient with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding requires the nurse to hold the dose and contact the
provider?
A. Serum potassium 3.1 mEq/L
B. Blood pressure 118/72 mm Hg
C. Heart rate 92 beats/min
D. Urine output 40 mL/hr
Correct Answer: A - Serum potassium 3.1 mEq/L
RATIONALE
Furosemide is a loop diuretic that can cause hypokalemia; a potassium
level of 3.1 mEq/L is below normal and increases risk of
dysrhythmias, so the dose should be held. The other values are within
normal limits and do not require holding the medication.
Question 2
The nurse is calculating the infusion rate for a patient prescribed 1,000 mL of
0.9% NaCl to infuse over 8 hours using an IV pump that delivers in mL/hr.
What rate should the nurse set?
A. 100 mL/hr
B. 125 mL/hr
C. 150 mL/hr
D. 80 mL/hr
Correct Answer: B - 125 mL/hr
RATIONALE
To calculate mL/hr, divide total volume (1,000 mL) by total hours (8),
which equals 125 mL/hr. The other options are incorrect calculations.
Page 2
, Question 3
A nurse is preparing to administer a blood transfusion. Which action is most
critical to prevent a hemolytic transfusion reaction?
A. Verify the blood product with another nurse using two identifiers.
B. Prime the tubing with 0.9% NaCl.
C. Administer the blood over 4 hours.
D. Premedicate with acetaminophen.
Correct Answer: A - Verify the blood product with another nurse
using two identifiers.
RATIONALE
Hemolytic reactions are most often caused by ABO incompatibility
due to misidentification; two-nurse verification with two patient
identifiers is the critical safety step. The other actions are important
but do not directly prevent hemolytic reactions.
Question 4
The nurse is assessing a patient with a suspected pulmonary embolism. Which
clinical finding is most consistent with this condition?
A. Sudden onset of pleuritic chest pain and dyspnea
B. Productive cough with yellow sputum
C. Bradycardia and hypertension
D. Wheezing and prolonged expiration
Correct Answer: A - Sudden onset of pleuritic chest pain and
dyspnea
RATIONALE
Pulmonary embolism typically presents with sudden dyspnea, pleuritic
chest pain, and tachycardia. The other findings are more consistent
with pneumonia, asthma, or other conditions.
Page 3
A patient with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding requires the nurse to hold the dose and contact the
provider?
A. Serum potassium 3.1 mEq/L
B. Blood pressure 118/72 mm Hg
C. Heart rate 92 beats/min
D. Urine output 40 mL/hr
Correct Answer: A - Serum potassium 3.1 mEq/L
RATIONALE
Furosemide is a loop diuretic that can cause hypokalemia; a potassium
level of 3.1 mEq/L is below normal and increases risk of
dysrhythmias, so the dose should be held. The other values are within
normal limits and do not require holding the medication.
Question 2
The nurse is calculating the infusion rate for a patient prescribed 1,000 mL of
0.9% NaCl to infuse over 8 hours using an IV pump that delivers in mL/hr.
What rate should the nurse set?
A. 100 mL/hr
B. 125 mL/hr
C. 150 mL/hr
D. 80 mL/hr
Correct Answer: B - 125 mL/hr
RATIONALE
To calculate mL/hr, divide total volume (1,000 mL) by total hours (8),
which equals 125 mL/hr. The other options are incorrect calculations.
Page 2
, Question 3
A nurse is preparing to administer a blood transfusion. Which action is most
critical to prevent a hemolytic transfusion reaction?
A. Verify the blood product with another nurse using two identifiers.
B. Prime the tubing with 0.9% NaCl.
C. Administer the blood over 4 hours.
D. Premedicate with acetaminophen.
Correct Answer: A - Verify the blood product with another nurse
using two identifiers.
RATIONALE
Hemolytic reactions are most often caused by ABO incompatibility
due to misidentification; two-nurse verification with two patient
identifiers is the critical safety step. The other actions are important
but do not directly prevent hemolytic reactions.
Question 4
The nurse is assessing a patient with a suspected pulmonary embolism. Which
clinical finding is most consistent with this condition?
A. Sudden onset of pleuritic chest pain and dyspnea
B. Productive cough with yellow sputum
C. Bradycardia and hypertension
D. Wheezing and prolonged expiration
Correct Answer: A - Sudden onset of pleuritic chest pain and
dyspnea
RATIONALE
Pulmonary embolism typically presents with sudden dyspnea, pleuritic
chest pain, and tachycardia. The other findings are more consistent
with pneumonia, asthma, or other conditions.
Page 3
