1. A patient on warfarin therapy has an INR of 4.5. What is the nurse’s
priority intervention?
A. Notify the healthcare provider.
B. Administer vitamin K as prescribed.
C. Hold the next dose of warfarin.
D. Assess the patient for signs of bleeding.
Answer and Rationale:
D. Assess the patient for signs of bleeding.
Rationale: An elevated INR increases the risk of bleeding, and
assessment ensures early detection of complications.
2. A patient is admitted with a potassium level of 6.5 mEq/L. Which
intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate).
B. Start an IV infusion of regular insulin and dextrose.
C. Monitor for peaked T waves on the ECG.
D. Administer calcium gluconate IV as prescribed.
Answer and Rationale:
D. Administer calcium gluconate IV as prescribed.
,Rationale: Calcium gluconate stabilizes the cardiac membrane and
prevents arrhythmias, which is the priority in hyperkalemia
management.
3. A progressive care nurse is caring for a patient with sepsis. Which
finding indicates the need for immediate intervention?
A. Blood pressure 90/60 mmHg
B. Heart rate 112 bpm
C. Lactate level 4 mmol/L
D. Temperature 38.5°C (101.3°F)
Answer and Rationale:
C. Lactate level 4 mmol/L
Rationale: A lactate level >2 mmol/L indicates tissue hypoperfusion
and possible organ dysfunction. Prompt interventions are needed to
address underlying sepsis.
4. A patient recovering from a thoracotomy has a respiratory rate of 28
breaths/min and is using accessory muscles to breathe. What is the
nurse’s first action?
A. Increase oxygen delivery.
B. Assess pain level and provide analgesia.
C. Perform a respiratory assessment.
D. Notify the healthcare provider.
, Answer and Rationale:
C. Perform a respiratory assessment.
Rationale: Identifying the underlying cause of respiratory distress is
essential before intervening.
5. A patient develops a sudden drop in SpO2 to 85% while on oxygen at
2 L/min via nasal cannula. What is the nurse’s first action?
A. Increase the oxygen flow rate.
B. Call the Rapid Response Team.
C. Assess airway patency and breath sounds.
D. Prepare for intubation.
Answer and Rationale:
C. Assess airway patency and breath sounds.
Rationale: Assessment is the priority to determine the cause of the
desaturation before taking further action.
6. A patient is receiving high-dose corticosteroids for acute
exacerbation of asthma. Which finding requires immediate action?
A. Blood glucose of 180 mg/dL
B. White blood cell count of 14,000/μL
C. Temperature of 101.5°F (38.6°C)
D. Heart rate of 92 bpm
priority intervention?
A. Notify the healthcare provider.
B. Administer vitamin K as prescribed.
C. Hold the next dose of warfarin.
D. Assess the patient for signs of bleeding.
Answer and Rationale:
D. Assess the patient for signs of bleeding.
Rationale: An elevated INR increases the risk of bleeding, and
assessment ensures early detection of complications.
2. A patient is admitted with a potassium level of 6.5 mEq/L. Which
intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate).
B. Start an IV infusion of regular insulin and dextrose.
C. Monitor for peaked T waves on the ECG.
D. Administer calcium gluconate IV as prescribed.
Answer and Rationale:
D. Administer calcium gluconate IV as prescribed.
,Rationale: Calcium gluconate stabilizes the cardiac membrane and
prevents arrhythmias, which is the priority in hyperkalemia
management.
3. A progressive care nurse is caring for a patient with sepsis. Which
finding indicates the need for immediate intervention?
A. Blood pressure 90/60 mmHg
B. Heart rate 112 bpm
C. Lactate level 4 mmol/L
D. Temperature 38.5°C (101.3°F)
Answer and Rationale:
C. Lactate level 4 mmol/L
Rationale: A lactate level >2 mmol/L indicates tissue hypoperfusion
and possible organ dysfunction. Prompt interventions are needed to
address underlying sepsis.
4. A patient recovering from a thoracotomy has a respiratory rate of 28
breaths/min and is using accessory muscles to breathe. What is the
nurse’s first action?
A. Increase oxygen delivery.
B. Assess pain level and provide analgesia.
C. Perform a respiratory assessment.
D. Notify the healthcare provider.
, Answer and Rationale:
C. Perform a respiratory assessment.
Rationale: Identifying the underlying cause of respiratory distress is
essential before intervening.
5. A patient develops a sudden drop in SpO2 to 85% while on oxygen at
2 L/min via nasal cannula. What is the nurse’s first action?
A. Increase the oxygen flow rate.
B. Call the Rapid Response Team.
C. Assess airway patency and breath sounds.
D. Prepare for intubation.
Answer and Rationale:
C. Assess airway patency and breath sounds.
Rationale: Assessment is the priority to determine the cause of the
desaturation before taking further action.
6. A patient is receiving high-dose corticosteroids for acute
exacerbation of asthma. Which finding requires immediate action?
A. Blood glucose of 180 mg/dL
B. White blood cell count of 14,000/μL
C. Temperature of 101.5°F (38.6°C)
D. Heart rate of 92 bpm
