, Question 1
A client receiving continuous heparin infusion has a new order for warfarin.
Which laboratory value best indicates that warfarin therapy has reached a
therapeutic effect while heparin is still infusing?
A. aPTT of 68 seconds
B. INR of 2.4
C. Platelet count of 110,000/mm3
D. Hemoglobin of 9.8 g/dL
Correct Answer: B - INR of 2.4
RATIONALE
Warfarin's therapeutic effect is monitored by INR (target 2-3 for most
indications), and an INR of 2.4 indicates adequate anticoagulation
from warfarin. aPTT reflects heparin, not warfarin, so it does not
confirm warfarin effect. Falling platelets and hemoglobin indicate
complications, not therapeutic warfarin effect.
Question 2
A client with acute decompensated heart failure is prescribed IV furosemide.
Which assessment finding requires the nurse to hold the dose and contact the
provider?
A. Urine output of 45 mL/hr
B. Serum potassium of 3.1 mEq/L
C. Blood pressure of 118/72 mm Hg
D. Respiratory rate of 22/min
Correct Answer: B - Serum potassium of 3.1 mEq/L
Page 2
, RATIONALE
Loop diuretics cause potassium wasting, and a serum potassium of 3.1
mEq/L is below the normal range and increases the risk of
dysrhythmias, so the dose should be held and the provider notified.
The other findings are within acceptable parameters and do not require
holding the dose.
Question 3
A client at 32 weeks gestation presents with painless, bright red vaginal
bleeding. Which action should the nurse take first?
A. Perform a sterile vaginal examination to assess dilation
B. Obtain a urine specimen for protein and glucose
C. Assess fetal heart tones and maternal vital signs
D. Administer betamethasone as ordered
Correct Answer: C - Assess fetal heart tones and maternal vital
signs
RATIONALE
Painless bright red bleeding in late pregnancy suggests placenta
previa, and the priority is to assess maternal and fetal status before any
intervention. Vaginal examination is contraindicated because it may
provoke severe hemorrhage. Betamethasone is important for fetal lung
maturity but is not the first action.
Question 4
A client with schizophrenia has been taking haloperidol and now exhibits a
stiff neck, fever of 39.2°C, and a creatine kinase of 1,800 U/L. Which
complication should the nurse suspect?
A. Acute dystonia
B. Neuroleptic malignant syndrome
C. Serotonin syndrome
D. Tardive dyskinesia
Page 3
, Correct Answer: B - Neuroleptic malignant syndrome
RATIONALE
Neuroleptic malignant syndrome is a life-threatening reaction to
antipsychotics characterized by rigidity, hyperthermia, autonomic
instability, and elevated creatine kinase. Acute dystonia involves
muscle spasms without fever or CK elevation. Serotonin syndrome
occurs with serotonergic drugs, and tardive dyskinesia is a late-onset
movement disorder.
Question 5
A nurse manager is assigning client care. Which task is most appropriate to
delegate to a licensed practical nurse (LPN)?
A. Administering IV push medication to a client with a central line
B. Performing an initial admission assessment on a new client
C. Reinforcing teaching about a new prescription with a stable client
D. Developing the plan of care for a client with a new diagnosis
Correct Answer: C - Reinforcing teaching about a new
prescription with a stable client
RATIONALE
Reinforcing teaching with a stable client is within the LPN's scope of
practice under the supervision of an RN. IV push medications via
central lines, initial assessments, and care plan development are RN
responsibilities that cannot be delegated to an LPN.
Question 6
A client with type 1 diabetes has a blood glucose of 52 mg/dL and is alert and
able to swallow. Which action should the nurse take first?
A. Administer 1 mg glucagon IM
B. Give 15 g of a fast-acting carbohydrate orally
C. Start an IV infusion of D5W
Page 4
A client receiving continuous heparin infusion has a new order for warfarin.
Which laboratory value best indicates that warfarin therapy has reached a
therapeutic effect while heparin is still infusing?
A. aPTT of 68 seconds
B. INR of 2.4
C. Platelet count of 110,000/mm3
D. Hemoglobin of 9.8 g/dL
Correct Answer: B - INR of 2.4
RATIONALE
Warfarin's therapeutic effect is monitored by INR (target 2-3 for most
indications), and an INR of 2.4 indicates adequate anticoagulation
from warfarin. aPTT reflects heparin, not warfarin, so it does not
confirm warfarin effect. Falling platelets and hemoglobin indicate
complications, not therapeutic warfarin effect.
Question 2
A client with acute decompensated heart failure is prescribed IV furosemide.
Which assessment finding requires the nurse to hold the dose and contact the
provider?
A. Urine output of 45 mL/hr
B. Serum potassium of 3.1 mEq/L
C. Blood pressure of 118/72 mm Hg
D. Respiratory rate of 22/min
Correct Answer: B - Serum potassium of 3.1 mEq/L
Page 2
, RATIONALE
Loop diuretics cause potassium wasting, and a serum potassium of 3.1
mEq/L is below the normal range and increases the risk of
dysrhythmias, so the dose should be held and the provider notified.
The other findings are within acceptable parameters and do not require
holding the dose.
Question 3
A client at 32 weeks gestation presents with painless, bright red vaginal
bleeding. Which action should the nurse take first?
A. Perform a sterile vaginal examination to assess dilation
B. Obtain a urine specimen for protein and glucose
C. Assess fetal heart tones and maternal vital signs
D. Administer betamethasone as ordered
Correct Answer: C - Assess fetal heart tones and maternal vital
signs
RATIONALE
Painless bright red bleeding in late pregnancy suggests placenta
previa, and the priority is to assess maternal and fetal status before any
intervention. Vaginal examination is contraindicated because it may
provoke severe hemorrhage. Betamethasone is important for fetal lung
maturity but is not the first action.
Question 4
A client with schizophrenia has been taking haloperidol and now exhibits a
stiff neck, fever of 39.2°C, and a creatine kinase of 1,800 U/L. Which
complication should the nurse suspect?
A. Acute dystonia
B. Neuroleptic malignant syndrome
C. Serotonin syndrome
D. Tardive dyskinesia
Page 3
, Correct Answer: B - Neuroleptic malignant syndrome
RATIONALE
Neuroleptic malignant syndrome is a life-threatening reaction to
antipsychotics characterized by rigidity, hyperthermia, autonomic
instability, and elevated creatine kinase. Acute dystonia involves
muscle spasms without fever or CK elevation. Serotonin syndrome
occurs with serotonergic drugs, and tardive dyskinesia is a late-onset
movement disorder.
Question 5
A nurse manager is assigning client care. Which task is most appropriate to
delegate to a licensed practical nurse (LPN)?
A. Administering IV push medication to a client with a central line
B. Performing an initial admission assessment on a new client
C. Reinforcing teaching about a new prescription with a stable client
D. Developing the plan of care for a client with a new diagnosis
Correct Answer: C - Reinforcing teaching about a new
prescription with a stable client
RATIONALE
Reinforcing teaching with a stable client is within the LPN's scope of
practice under the supervision of an RN. IV push medications via
central lines, initial assessments, and care plan development are RN
responsibilities that cannot be delegated to an LPN.
Question 6
A client with type 1 diabetes has a blood glucose of 52 mg/dL and is alert and
able to swallow. Which action should the nurse take first?
A. Administer 1 mg glucagon IM
B. Give 15 g of a fast-acting carbohydrate orally
C. Start an IV infusion of D5W
Page 4
