1. Which lab value is most concerning for a patient receiving heparin
therapy?
A. Platelet count: 95,000/μL
B. Hemoglobin: 12 g/dL
C. INR: 1.2
D. aPTT: 70 seconds
Answer and Rationale:
A. Platelet count: 95,000/μL
Rationale: A low platelet count could indicate heparin-induced
thrombocytopenia (HIT), a potentially life-threatening condition. The
other values are less immediately concerning in this context.
2. A postoperative patient has a blood pressure of 88/58 mmHg, heart
rate of 122 bpm, and cold, clammy skin. What is the nurse’s priority?
A. Administer a prescribed vasopressor.
B. Start a fluid bolus as prescribed.
C. Notify the healthcare provider.
D. Monitor urine output.
Answer and Rationale:
B. Start a fluid bolus as prescribed.
,Rationale: These are signs of hypovolemic shock, and fluid resuscitation
is the first-line treatment.
3. 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.
4. The nurse notes that a patient receiving a blood transfusion develops
a fever, chills, and low back pain. What is the nurse’s priority action?
A. Slow the infusion rate.
B. Stop the transfusion immediately.
C. Administer acetaminophen.
D. Notify the healthcare provider.
Answer and Rationale:
B. Stop the transfusion immediately.
, Rationale: These symptoms indicate a possible transfusion reaction,
which requires stopping the transfusion to prevent further
complications.
5. A patient receiving furosemide complains of muscle cramps. Which
lab value should the nurse assess?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Answer and Rationale:
C. Potassium
Rationale: Hypokalemia is a common side effect of furosemide and can
cause muscle cramps.
6. A patient with a pulmonary embolism is started on a heparin
infusion. Which lab value should the nurse monitor closely?
A. PT/INR
B. aPTT
C. Platelet count
D. D-dimer
Answer and Rationale:
B. aPTT
therapy?
A. Platelet count: 95,000/μL
B. Hemoglobin: 12 g/dL
C. INR: 1.2
D. aPTT: 70 seconds
Answer and Rationale:
A. Platelet count: 95,000/μL
Rationale: A low platelet count could indicate heparin-induced
thrombocytopenia (HIT), a potentially life-threatening condition. The
other values are less immediately concerning in this context.
2. A postoperative patient has a blood pressure of 88/58 mmHg, heart
rate of 122 bpm, and cold, clammy skin. What is the nurse’s priority?
A. Administer a prescribed vasopressor.
B. Start a fluid bolus as prescribed.
C. Notify the healthcare provider.
D. Monitor urine output.
Answer and Rationale:
B. Start a fluid bolus as prescribed.
,Rationale: These are signs of hypovolemic shock, and fluid resuscitation
is the first-line treatment.
3. 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.
4. The nurse notes that a patient receiving a blood transfusion develops
a fever, chills, and low back pain. What is the nurse’s priority action?
A. Slow the infusion rate.
B. Stop the transfusion immediately.
C. Administer acetaminophen.
D. Notify the healthcare provider.
Answer and Rationale:
B. Stop the transfusion immediately.
, Rationale: These symptoms indicate a possible transfusion reaction,
which requires stopping the transfusion to prevent further
complications.
5. A patient receiving furosemide complains of muscle cramps. Which
lab value should the nurse assess?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Answer and Rationale:
C. Potassium
Rationale: Hypokalemia is a common side effect of furosemide and can
cause muscle cramps.
6. A patient with a pulmonary embolism is started on a heparin
infusion. Which lab value should the nurse monitor closely?
A. PT/INR
B. aPTT
C. Platelet count
D. D-dimer
Answer and Rationale:
B. aPTT
