250 Practice Questions & Solutions |
Rationales | Instant PDF Download
SECTION 1: SAFE AND EFFECTIVE CARE ENVIRONMENT –
COORDINATED CARE (Questions 1–25)
1. A nurse is caring for a client who has a new prescription for
warfarin. Which of the following laboratory values should the nurse
monitor to evaluate the effectiveness of the medication?
A) Activated partial thromboplastin time (aPTT)
B) International normalized ratio (INR)
C) Platelet count
D) Bleeding time
Answer: B
Rationale: Warfarin is an anticoagulant that inhibits vitamin K-dependent
clotting factors. The INR is the standard laboratory test used to monitor
warfarin therapy. The therapeutic INR range is typically 2.0 to 3.0. aPTT is
used to monitor heparin therapy.
,2. A nurse is preparing to administer medications to a client. Which of
the following actions should the nurse take first?
A) Check the medication against the medication administration record
(MAR)
B) Verify the client's identification using two identifiers
C) Assess the client for allergies
D) Perform hand hygiene
Answer: D
Rationale: Hand hygiene is the first action before any client contact or
medication preparation. It is the most effective way to prevent the spread
of infection.
3. A nurse is delegating tasks to a nursing assistant. Which of the
following tasks is appropriate for the nurse to delegate?
A) Administering oral medications
B) Assessing a client's wound
C) Ambulating a stable client
D) Teaching a client about a new medication
Answer: C
Rationale: Ambulating a stable client is a task that can be safely delegated
to a nursing assistant. Medication administration, assessment, and
teaching require the skill and judgment of a licensed nurse.
,4. A nurse is reviewing the medical record of a client who has a
prescription for digoxin. Which of the following findings should the
nurse report to the provider?
A) Heart rate 88/min
B) Potassium 3.2 mEq/L
C) Digoxin level 1.2 ng/mL
D) Blood pressure 128/76 mm Hg
Answer: B
Rationale: Hypokalemia increases the risk of digoxin toxicity. The nurse
should report a potassium level below 3.5 mEq/L to the provider before
administering digoxin.
5. A nurse is caring for a client who is scheduled for surgery. Which of
the following actions should the nurse take to verify the client has
given informed consent?
A) Ask the client to sign the consent form
B) Verify the provider explained the procedure and the client understands
C) Witness the client's signature on the consent form
D) Confirm the client has a power of attorney
Answer: B
, Rationale: The nurse's role in informed consent is to verify that the
provider explained the procedure, risks, benefits, and alternatives, and
that the client understands and voluntarily consents.
6. A nurse is prioritizing care for four clients. Which client should the
nurse assess first?
A) Client who is 1 day postoperative and reports pain at a 4 on a 0–10
scale
B) Client who has a new onset of confusion and agitation
C) Client who is requesting assistance to ambulate to the bathroom
D) Client who needs discharge teaching about a new medication
Answer: B
Rationale: A new onset of confusion and agitation may indicate a serious
complication such as hypoxia, hypoglycemia, or infection. This client
requires immediate assessment.
7. A nurse is preparing to administer a blood transfusion. Which of
the following actions should the nurse take?
A) Prime the tubing with dextrose 5% in water
B) Verify the blood product with another nurse using two identifiers
C) Administer the blood over 6 hours
D) Add medications to the blood bag as prescribed