, Question 1
A patient with septic shock is receiving a norepinephrine infusion at 0.1
mcg/kg/min via a peripheral IV. The provider orders the concentration changed
to 16 mg in 250 mL D5W. Which action should the nurse take first?
A. Continue the infusion at the current rate and document the
concentration change.
B. Stop the infusion and request central line placement before restarting.
C. Verify the new concentration with an independent double-check and
reprogram the smart pump.
D. Increase the rate to compensate for the lower concentration.
Correct Answer: C - Verify the new concentration with an
independent double-check and reprogram the smart pump.
RATIONALE
Norepinephrine is an ISMP high-alert medication; any concentration
change requires an independent double-check and smart-pump
reprogramming to prevent dosing errors. Stopping the infusion may
cause hemodynamic collapse, and rate changes must be based on
prescribed dose, not concentration assumptions.
Question 2
A patient on warfarin for atrial fibrillation has an INR of 7.8 and is actively
bleeding from the gums. Which intervention is most appropriate?
A. Administer vitamin K 10 mg IV push and hold warfarin.
B. Administer 4-factor prothrombin complex concentrate (PCC) plus
vitamin K 5 mg IV.
C. Transfuse 2 units of fresh frozen plasma and continue warfarin.
D. Administer protamine sulfate 50 mg IV and monitor aPTT.
Correct Answer: B - Administer 4-factor prothrombin complex
concentrate (PCC) plus vitamin K 5 mg IV.
Page 2
, RATIONALE
For life-threatening or active bleeding with supratherapeutic INR,
guidelines recommend 4-factor PCC plus IV vitamin K for rapid
reversal. Vitamin K alone is too slow, FFP requires large volumes and
is slower than PCC, and protamine reverses heparin, not warfarin.
Question 3
A patient with COPD (GOLD 2026 group E) is started on triple therapy.
Which combination reflects current GOLD 2026 recommendations for this
patient?
A. LAMA + LABA + inhaled corticosteroid
B. SABA + LAMA + theophylline
C. LABA + inhaled corticosteroid + montelukast
D. LAMA + roflumilast + azithromycin
Correct Answer: A - LAMA + LABA + inhaled corticosteroid
RATIONALE
GOLD 2026 recommends LAMA+LABA+ICS for group E patients
with frequent exacerbations and elevated eosinophils.
SABA+theophylline is not triple therapy, montelukast is not first-line,
and roflumilast/azithromycin are add-on therapies for select patients.
Question 4
A patient receiving IV vancomycin has a trough level of 22 mcg/mL (target
15-20 mcg/mL) and a serum creatinine that has risen from 0.9 to 1.6 mg/dL.
Which action should the nurse anticipate?
A. Continue the current dose and recheck the trough in 48 hours.
B. Hold the next dose and notify the provider for dose adjustment.
C. Administer the next dose and increase the infusion rate.
D. Request a peak level to confirm therapeutic range.
Correct Answer: B - Hold the next dose and notify the provider
Page 3
, for dose adjustment.
RATIONALE
An elevated trough with rising creatinine indicates possible
vancomycin-induced nephrotoxicity; the next dose should be held and
the provider notified for dose adjustment. Continuing or increasing the
dose worsens toxicity, and peak levels are not used for routine
vancomycin monitoring.
Question 5
A patient with bipolar disorder on lithium carbonate reports a 3-day history of
vomiting and diarrhea. The lithium level is 1.8 mEq/L. Which finding is most
consistent with this level?
A. Fine hand tremor and polyuria
B. Coarse tremor, ataxia, and confusion
C. Seizures and coma
D. No symptoms; level is therapeutic
Correct Answer: B - Coarse tremor, ataxia, and confusion
RATIONALE
Lithium levels of 1.5-2.0 mEq/L produce moderate toxicity with
coarse tremor, ataxia, and confusion. Fine tremor and polyuria are
early signs, seizures/coma indicate severe toxicity >2.5 mEq/L, and
1.8 is above the therapeutic range of 0.6-1.2 mEq/L.
Question 6
A patient is prescribed digoxin 0.125 mg IV push. Which assessment finding
requires the nurse to hold the dose and notify the provider?
A. Heart rate 58 beats/min and potassium 3.2 mEq/L
B. Heart rate 88 beats/min and potassium 4.0 mEq/L
C. Blood pressure 110/70 mm Hg and sodium 138 mEq/L
D. Respiratory rate 18/min and calcium 9.0 mg/dL
Page 4
A patient with septic shock is receiving a norepinephrine infusion at 0.1
mcg/kg/min via a peripheral IV. The provider orders the concentration changed
to 16 mg in 250 mL D5W. Which action should the nurse take first?
A. Continue the infusion at the current rate and document the
concentration change.
B. Stop the infusion and request central line placement before restarting.
C. Verify the new concentration with an independent double-check and
reprogram the smart pump.
D. Increase the rate to compensate for the lower concentration.
Correct Answer: C - Verify the new concentration with an
independent double-check and reprogram the smart pump.
RATIONALE
Norepinephrine is an ISMP high-alert medication; any concentration
change requires an independent double-check and smart-pump
reprogramming to prevent dosing errors. Stopping the infusion may
cause hemodynamic collapse, and rate changes must be based on
prescribed dose, not concentration assumptions.
Question 2
A patient on warfarin for atrial fibrillation has an INR of 7.8 and is actively
bleeding from the gums. Which intervention is most appropriate?
A. Administer vitamin K 10 mg IV push and hold warfarin.
B. Administer 4-factor prothrombin complex concentrate (PCC) plus
vitamin K 5 mg IV.
C. Transfuse 2 units of fresh frozen plasma and continue warfarin.
D. Administer protamine sulfate 50 mg IV and monitor aPTT.
Correct Answer: B - Administer 4-factor prothrombin complex
concentrate (PCC) plus vitamin K 5 mg IV.
Page 2
, RATIONALE
For life-threatening or active bleeding with supratherapeutic INR,
guidelines recommend 4-factor PCC plus IV vitamin K for rapid
reversal. Vitamin K alone is too slow, FFP requires large volumes and
is slower than PCC, and protamine reverses heparin, not warfarin.
Question 3
A patient with COPD (GOLD 2026 group E) is started on triple therapy.
Which combination reflects current GOLD 2026 recommendations for this
patient?
A. LAMA + LABA + inhaled corticosteroid
B. SABA + LAMA + theophylline
C. LABA + inhaled corticosteroid + montelukast
D. LAMA + roflumilast + azithromycin
Correct Answer: A - LAMA + LABA + inhaled corticosteroid
RATIONALE
GOLD 2026 recommends LAMA+LABA+ICS for group E patients
with frequent exacerbations and elevated eosinophils.
SABA+theophylline is not triple therapy, montelukast is not first-line,
and roflumilast/azithromycin are add-on therapies for select patients.
Question 4
A patient receiving IV vancomycin has a trough level of 22 mcg/mL (target
15-20 mcg/mL) and a serum creatinine that has risen from 0.9 to 1.6 mg/dL.
Which action should the nurse anticipate?
A. Continue the current dose and recheck the trough in 48 hours.
B. Hold the next dose and notify the provider for dose adjustment.
C. Administer the next dose and increase the infusion rate.
D. Request a peak level to confirm therapeutic range.
Correct Answer: B - Hold the next dose and notify the provider
Page 3
, for dose adjustment.
RATIONALE
An elevated trough with rising creatinine indicates possible
vancomycin-induced nephrotoxicity; the next dose should be held and
the provider notified for dose adjustment. Continuing or increasing the
dose worsens toxicity, and peak levels are not used for routine
vancomycin monitoring.
Question 5
A patient with bipolar disorder on lithium carbonate reports a 3-day history of
vomiting and diarrhea. The lithium level is 1.8 mEq/L. Which finding is most
consistent with this level?
A. Fine hand tremor and polyuria
B. Coarse tremor, ataxia, and confusion
C. Seizures and coma
D. No symptoms; level is therapeutic
Correct Answer: B - Coarse tremor, ataxia, and confusion
RATIONALE
Lithium levels of 1.5-2.0 mEq/L produce moderate toxicity with
coarse tremor, ataxia, and confusion. Fine tremor and polyuria are
early signs, seizures/coma indicate severe toxicity >2.5 mEq/L, and
1.8 is above the therapeutic range of 0.6-1.2 mEq/L.
Question 6
A patient is prescribed digoxin 0.125 mg IV push. Which assessment finding
requires the nurse to hold the dose and notify the provider?
A. Heart rate 58 beats/min and potassium 3.2 mEq/L
B. Heart rate 88 beats/min and potassium 4.0 mEq/L
C. Blood pressure 110/70 mm Hg and sodium 138 mEq/L
D. Respiratory rate 18/min and calcium 9.0 mg/dL
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