, Question 1
A client with acute decompensated heart failure is receiving a continuous
furosemide infusion. Which set of assessment findings best indicates the
infusion is producing the desired therapeutic effect without causing harm?
A. Urine output 90 mL/hr, serum potassium 3.1 mEq/L, weight down 1
kg
B. Urine output 120 mL/hr, serum potassium 4.0 mEq/L, weight down 2
kg over 24 hr
C. Urine output 40 mL/hr, serum potassium 4.5 mEq/L, weight
unchanged
D. Urine output 200 mL/hr, serum potassium 3.4 mEq/L, weight down 3
kg over 8 hr
Correct Answer: B - Urine output 120 mL/hr, serum potassium
4.0 mEq/L, weight down 2 kg over 24 hr
RATIONALE
Adequate diuresis (roughly 0.5-1 kg/day weight loss) with normal
potassium indicates effective, safe decongestion. Option A shows
hypokalemia risk, C shows inadequate response, and D reflects overly
rapid diuresis with electrolyte derangement.
Question 2
A client receiving a continuous heparin infusion for venous thromboembolism
has an aPTT of 105 seconds (therapeutic range 60-80 seconds). Which action is
the nurse's priority?
A. Continue the infusion and recheck aPTT in 6 hours.
B. Stop the infusion and prepare to administer protamine sulfate.
C. Hold the infusion and notify the provider for dose adjustment.
D. Increase the infusion rate to maintain therapeutic anticoagulation.
Correct Answer: C - Hold the infusion and notify the provider for
dose adjustment.
Page 2
, RATIONALE
An aPTT of 105 seconds exceeds the therapeutic range, indicating
supratherapeutic anticoagulation; the infusion should be held and the
provider notified. Protamine is reserved for active bleeding or extreme
elevation, and continuing or increasing the dose would worsen
bleeding risk.
Question 3
A client with type 1 diabetes has a blood glucose of 580 mg/dL, pH 7.12,
bicarbonate 8 mEq/L, and positive serum ketones. Which prescription should
the nurse question?
A. 0.9% sodium chloride IV bolus
B. Regular insulin IV infusion
C. Sodium bicarbonate IV push
D. Potassium chloride 20 mEq IV added to the infusion after potassium is
4.1 mEq/L
Correct Answer: C - Sodium bicarbonate IV push
RATIONALE
Sodium bicarbonate is not routinely indicated in diabetic ketoacidosis
unless pH is <6.9, due to risks of paradoxical CNS acidosis and
hypokalemia. Fluid resuscitation, insulin infusion, and potassium
replacement (once potassium is confirmed adequate) are standard.
Question 4
A client is 12 hours post-coronary artery bypass graft with a mediastinal chest
tube. Which finding requires immediate intervention?
A. Serosanguineous drainage of 50 mL in the last hour
B. Sudden cessation of drainage with hypotension and muffled heart
sounds
C. Intermittent bubbling in the water-seal chamber
D. Chest tube drainage of 200 mL in the first 8 hours
Page 3
, Correct Answer: B - Sudden cessation of drainage with
hypotension and muffled heart sounds
RATIONALE
Sudden cessation of mediastinal drainage with hypotension and
muffled heart sounds suggests cardiac tamponade from clot
obstruction. Serosanguineous drainage, intermittent bubbling, and
moderate early drainage are expected post-CABG findings.
Question 5
A laboring client at 41 weeks gestation has a Category III fetal heart rate
tracing. Which nursing action is most appropriate?
A. Reposition to left lateral, administer oxygen, and prepare for
emergency cesarean delivery.
B. Continue monitoring and document the tracing.
C. Administer terbutaline to reduce uterine activity.
D. Perform a sterile vaginal exam to assess dilation.
Correct Answer: A - Reposition to left lateral, administer oxygen,
and prepare for emergency cesarean delivery.
RATIONALE
A Category III tracing indicates abnormal fetal acid-base status and
requires intrauterine resuscitation and preparation for expedited
delivery. Continuing to monitor, giving terbutaline, or performing a
vaginal exam alone delays necessary intervention.
Question 6
A client with a traumatic brain injury has an intracranial pressure (ICP) of 22
mmHg and a cerebral perfusion pressure (CPP) of 55 mmHg. Which
intervention should the nurse anticipate?
A. Administer hypotonic IV fluids to improve perfusion.
B. Elevate the head of bed to 30 degrees and maintain normocapnia.
Page 4
A client with acute decompensated heart failure is receiving a continuous
furosemide infusion. Which set of assessment findings best indicates the
infusion is producing the desired therapeutic effect without causing harm?
A. Urine output 90 mL/hr, serum potassium 3.1 mEq/L, weight down 1
kg
B. Urine output 120 mL/hr, serum potassium 4.0 mEq/L, weight down 2
kg over 24 hr
C. Urine output 40 mL/hr, serum potassium 4.5 mEq/L, weight
unchanged
D. Urine output 200 mL/hr, serum potassium 3.4 mEq/L, weight down 3
kg over 8 hr
Correct Answer: B - Urine output 120 mL/hr, serum potassium
4.0 mEq/L, weight down 2 kg over 24 hr
RATIONALE
Adequate diuresis (roughly 0.5-1 kg/day weight loss) with normal
potassium indicates effective, safe decongestion. Option A shows
hypokalemia risk, C shows inadequate response, and D reflects overly
rapid diuresis with electrolyte derangement.
Question 2
A client receiving a continuous heparin infusion for venous thromboembolism
has an aPTT of 105 seconds (therapeutic range 60-80 seconds). Which action is
the nurse's priority?
A. Continue the infusion and recheck aPTT in 6 hours.
B. Stop the infusion and prepare to administer protamine sulfate.
C. Hold the infusion and notify the provider for dose adjustment.
D. Increase the infusion rate to maintain therapeutic anticoagulation.
Correct Answer: C - Hold the infusion and notify the provider for
dose adjustment.
Page 2
, RATIONALE
An aPTT of 105 seconds exceeds the therapeutic range, indicating
supratherapeutic anticoagulation; the infusion should be held and the
provider notified. Protamine is reserved for active bleeding or extreme
elevation, and continuing or increasing the dose would worsen
bleeding risk.
Question 3
A client with type 1 diabetes has a blood glucose of 580 mg/dL, pH 7.12,
bicarbonate 8 mEq/L, and positive serum ketones. Which prescription should
the nurse question?
A. 0.9% sodium chloride IV bolus
B. Regular insulin IV infusion
C. Sodium bicarbonate IV push
D. Potassium chloride 20 mEq IV added to the infusion after potassium is
4.1 mEq/L
Correct Answer: C - Sodium bicarbonate IV push
RATIONALE
Sodium bicarbonate is not routinely indicated in diabetic ketoacidosis
unless pH is <6.9, due to risks of paradoxical CNS acidosis and
hypokalemia. Fluid resuscitation, insulin infusion, and potassium
replacement (once potassium is confirmed adequate) are standard.
Question 4
A client is 12 hours post-coronary artery bypass graft with a mediastinal chest
tube. Which finding requires immediate intervention?
A. Serosanguineous drainage of 50 mL in the last hour
B. Sudden cessation of drainage with hypotension and muffled heart
sounds
C. Intermittent bubbling in the water-seal chamber
D. Chest tube drainage of 200 mL in the first 8 hours
Page 3
, Correct Answer: B - Sudden cessation of drainage with
hypotension and muffled heart sounds
RATIONALE
Sudden cessation of mediastinal drainage with hypotension and
muffled heart sounds suggests cardiac tamponade from clot
obstruction. Serosanguineous drainage, intermittent bubbling, and
moderate early drainage are expected post-CABG findings.
Question 5
A laboring client at 41 weeks gestation has a Category III fetal heart rate
tracing. Which nursing action is most appropriate?
A. Reposition to left lateral, administer oxygen, and prepare for
emergency cesarean delivery.
B. Continue monitoring and document the tracing.
C. Administer terbutaline to reduce uterine activity.
D. Perform a sterile vaginal exam to assess dilation.
Correct Answer: A - Reposition to left lateral, administer oxygen,
and prepare for emergency cesarean delivery.
RATIONALE
A Category III tracing indicates abnormal fetal acid-base status and
requires intrauterine resuscitation and preparation for expedited
delivery. Continuing to monitor, giving terbutaline, or performing a
vaginal exam alone delays necessary intervention.
Question 6
A client with a traumatic brain injury has an intracranial pressure (ICP) of 22
mmHg and a cerebral perfusion pressure (CPP) of 55 mmHg. Which
intervention should the nurse anticipate?
A. Administer hypotonic IV fluids to improve perfusion.
B. Elevate the head of bed to 30 degrees and maintain normocapnia.
Page 4
