1. The nurse notices a peaked T wave on the ECG of a patient with
chronic kidney disease. What is the nurse’s priority?
A. Notify the healthcare provider.
B. Administer sodium bicarbonate.
C. Administer calcium gluconate.
D. Check the patient’s potassium level.
Answer and Rationale:
D. Check the patient’s potassium level.
Rationale: Peaked T waves suggest hyperkalemia. Verifying the
potassium level is essential to guide treatment.
2. A patient recovering from a myocardial infarction is receiving a beta-
blocker. Which assessment finding requires immediate intervention?
A. Heart rate of 58 bpm
B. Blood pressure of 100/60 mmHg
C. Wheezing during lung auscultation
D. Fatigue and weakness
Answer and Rationale:
C. Wheezing during lung auscultation
,Rationale: Wheezing may indicate bronchospasm, a potential adverse
effect of beta-blockers, especially in patients with reactive airway
diseases.
3. A patient on enoxaparin for DVT prophylaxis has a platelet count of
80,000/μL. What is the nurse’s priority action?
A. Notify the healthcare provider.
B. Assess for signs of bleeding.
C. Stop enoxaparin administration.
D. Monitor the platelet count daily.
Answer and Rationale:
A. Notify the healthcare provider.
Rationale: A low platelet count may indicate HIT, which requires
immediate medical evaluation and possible discontinuation of
enoxaparin.
4. A patient has a central venous catheter and reports sudden shortness
of breath. The nurse notices decreased oxygen saturation and
hypotension. What is the priority intervention?
A. Administer a prescribed diuretic.
B. Position the patient on their left side with the head down.
C. Notify the healthcare provider immediately.
D. Remove the central venous catheter.
, Answer and Rationale:
B. Position the patient on their left side with the head down.
Rationale: This position traps air in the right atrium, minimizing the
risk of air embolism traveling to the lungs or brain.
5. A patient on a ventilator has a high-pressure alarm sounding. What
is the nurse’s first action?
A. Check the tubing for kinks or obstructions.
B. Silence the alarm and monitor the patient.
C. Notify the respiratory therapist.
D. Decrease the ventilator settings.
Answer and Rationale:
A. Check the tubing for kinks or obstructions.
Rationale: High-pressure alarms often indicate obstructions in the
circuit, which should be assessed first.
6. A patient on warfarin reports black tarry stools. What is the nurse’s
first action?
A. Notify the healthcare provider immediately.
B. Hold the next dose of warfarin.
C. Check the INR level.
D. Assess for signs of bleeding.
Answer and Rationale:
chronic kidney disease. What is the nurse’s priority?
A. Notify the healthcare provider.
B. Administer sodium bicarbonate.
C. Administer calcium gluconate.
D. Check the patient’s potassium level.
Answer and Rationale:
D. Check the patient’s potassium level.
Rationale: Peaked T waves suggest hyperkalemia. Verifying the
potassium level is essential to guide treatment.
2. A patient recovering from a myocardial infarction is receiving a beta-
blocker. Which assessment finding requires immediate intervention?
A. Heart rate of 58 bpm
B. Blood pressure of 100/60 mmHg
C. Wheezing during lung auscultation
D. Fatigue and weakness
Answer and Rationale:
C. Wheezing during lung auscultation
,Rationale: Wheezing may indicate bronchospasm, a potential adverse
effect of beta-blockers, especially in patients with reactive airway
diseases.
3. A patient on enoxaparin for DVT prophylaxis has a platelet count of
80,000/μL. What is the nurse’s priority action?
A. Notify the healthcare provider.
B. Assess for signs of bleeding.
C. Stop enoxaparin administration.
D. Monitor the platelet count daily.
Answer and Rationale:
A. Notify the healthcare provider.
Rationale: A low platelet count may indicate HIT, which requires
immediate medical evaluation and possible discontinuation of
enoxaparin.
4. A patient has a central venous catheter and reports sudden shortness
of breath. The nurse notices decreased oxygen saturation and
hypotension. What is the priority intervention?
A. Administer a prescribed diuretic.
B. Position the patient on their left side with the head down.
C. Notify the healthcare provider immediately.
D. Remove the central venous catheter.
, Answer and Rationale:
B. Position the patient on their left side with the head down.
Rationale: This position traps air in the right atrium, minimizing the
risk of air embolism traveling to the lungs or brain.
5. A patient on a ventilator has a high-pressure alarm sounding. What
is the nurse’s first action?
A. Check the tubing for kinks or obstructions.
B. Silence the alarm and monitor the patient.
C. Notify the respiratory therapist.
D. Decrease the ventilator settings.
Answer and Rationale:
A. Check the tubing for kinks or obstructions.
Rationale: High-pressure alarms often indicate obstructions in the
circuit, which should be assessed first.
6. A patient on warfarin reports black tarry stools. What is the nurse’s
first action?
A. Notify the healthcare provider immediately.
B. Hold the next dose of warfarin.
C. Check the INR level.
D. Assess for signs of bleeding.
Answer and Rationale:
