, Question 1
A patient with a new ileostomy has high-output liquid stool. Which assessment
finding most urgently indicates the need for immediate intervention?
A. Stoma output of 1200 mL over 24 hours
B. Serum potassium of 3.2 mEq/L
C. Blood urea nitrogen (BUN) of 28 mg/dL
D. Stoma appears dark red and moist
Correct Answer: B - Serum potassium of 3.2 mEq/L
RATIONALE
High-output ileostomies cause significant potassium loss; a level of
3.2 mEq/L indicates hypokalemia, which can precipitate
life-threatening arrhythmias. While output and BUN are concerning,
hypokalemia requires immediate intervention. A dark red, moist stoma
is normal.
Question 2
A patient is prescribed enoxaparin 1 mg/kg subcutaneously every 12 hours.
Which laboratory value requires the nurse to hold the dose and notify the
provider?
A. Platelet count 80,000/mm³
B. Hemoglobin 11.2 g/dL
C. International normalized ratio (INR) 1.2
D. Activated partial thromboplastin time (aPTT) 35 seconds
Correct Answer: A - Platelet count 80,000/mm³
RATIONALE
Enoxaparin can cause heparin-induced thrombocytopenia (HIT); a
platelet count <100,000/mm³ or a 50% drop requires holding the dose.
The other values are within normal limits or not directly affected by
enoxaparin monitoring.
Page 2
, Question 3
A patient with acute heart failure is prescribed furosemide IV. Which
assessment finding indicates the medication is having the desired effect?
A. Urine output of 50 mL/hr
B. Decreased crackles in lung bases
C. Serum potassium 3.0 mEq/L
D. Blood pressure 90/60 mm Hg
Correct Answer: B - Decreased crackles in lung bases
RATIONALE
Furosemide reduces preload by promoting diuresis, leading to
decreased pulmonary congestion and crackles. Urine output is a
secondary indicator; hypokalemia and hypotension are adverse effects,
not desired outcomes.
Question 4
A patient is scheduled for surgery and has a history of malignant hyperthermia.
Which anesthetic agent should the nurse anticipate the provider will avoid?
A. Propofol
B. Succinylcholine
C. Midazolam
D. Fentanyl
Correct Answer: B - Succinylcholine
RATIONALE
Succinylcholine is a triggering agent for malignant hyperthermia.
Propofol, midazolam, and fentanyl are safe alternatives. The nurse
must ensure a MH-safe anesthesia plan.
Page 3
, Question 5
A patient is receiving a blood transfusion and develops fever, chills, and flank
pain. Which action should the nurse take first?
A. Administer acetaminophen
B. Stop the transfusion and maintain IV access
C. Slow the transfusion rate
D. Obtain a urine specimen
Correct Answer: B - Stop the transfusion and maintain IV access
RATIONALE
These signs suggest an acute hemolytic transfusion reaction; the
priority is to stop the transfusion immediately and keep the IV line
patent with normal saline. Administering medication or slowing the
rate delays critical intervention.
Question 6
A patient with a new colostomy has a stoma that is dark purple and dry. Which
action should the nurse take?
A. Apply a moisture-barrier cream
B. Notify the provider immediately
C. Document the finding as normal
D. Increase fluid intake
Correct Answer: B - Notify the provider immediately
RATIONALE
A dark purple, dry stoma indicates ischemia and possible necrosis,
requiring immediate provider notification. Normal stomas are pink to
red and moist. Creams or fluid changes do not address the underlying
ischemia.
Page 4
A patient with a new ileostomy has high-output liquid stool. Which assessment
finding most urgently indicates the need for immediate intervention?
A. Stoma output of 1200 mL over 24 hours
B. Serum potassium of 3.2 mEq/L
C. Blood urea nitrogen (BUN) of 28 mg/dL
D. Stoma appears dark red and moist
Correct Answer: B - Serum potassium of 3.2 mEq/L
RATIONALE
High-output ileostomies cause significant potassium loss; a level of
3.2 mEq/L indicates hypokalemia, which can precipitate
life-threatening arrhythmias. While output and BUN are concerning,
hypokalemia requires immediate intervention. A dark red, moist stoma
is normal.
Question 2
A patient is prescribed enoxaparin 1 mg/kg subcutaneously every 12 hours.
Which laboratory value requires the nurse to hold the dose and notify the
provider?
A. Platelet count 80,000/mm³
B. Hemoglobin 11.2 g/dL
C. International normalized ratio (INR) 1.2
D. Activated partial thromboplastin time (aPTT) 35 seconds
Correct Answer: A - Platelet count 80,000/mm³
RATIONALE
Enoxaparin can cause heparin-induced thrombocytopenia (HIT); a
platelet count <100,000/mm³ or a 50% drop requires holding the dose.
The other values are within normal limits or not directly affected by
enoxaparin monitoring.
Page 2
, Question 3
A patient with acute heart failure is prescribed furosemide IV. Which
assessment finding indicates the medication is having the desired effect?
A. Urine output of 50 mL/hr
B. Decreased crackles in lung bases
C. Serum potassium 3.0 mEq/L
D. Blood pressure 90/60 mm Hg
Correct Answer: B - Decreased crackles in lung bases
RATIONALE
Furosemide reduces preload by promoting diuresis, leading to
decreased pulmonary congestion and crackles. Urine output is a
secondary indicator; hypokalemia and hypotension are adverse effects,
not desired outcomes.
Question 4
A patient is scheduled for surgery and has a history of malignant hyperthermia.
Which anesthetic agent should the nurse anticipate the provider will avoid?
A. Propofol
B. Succinylcholine
C. Midazolam
D. Fentanyl
Correct Answer: B - Succinylcholine
RATIONALE
Succinylcholine is a triggering agent for malignant hyperthermia.
Propofol, midazolam, and fentanyl are safe alternatives. The nurse
must ensure a MH-safe anesthesia plan.
Page 3
, Question 5
A patient is receiving a blood transfusion and develops fever, chills, and flank
pain. Which action should the nurse take first?
A. Administer acetaminophen
B. Stop the transfusion and maintain IV access
C. Slow the transfusion rate
D. Obtain a urine specimen
Correct Answer: B - Stop the transfusion and maintain IV access
RATIONALE
These signs suggest an acute hemolytic transfusion reaction; the
priority is to stop the transfusion immediately and keep the IV line
patent with normal saline. Administering medication or slowing the
rate delays critical intervention.
Question 6
A patient with a new colostomy has a stoma that is dark purple and dry. Which
action should the nurse take?
A. Apply a moisture-barrier cream
B. Notify the provider immediately
C. Document the finding as normal
D. Increase fluid intake
Correct Answer: B - Notify the provider immediately
RATIONALE
A dark purple, dry stoma indicates ischemia and possible necrosis,
requiring immediate provider notification. Normal stomas are pink to
red and moist. Creams or fluid changes do not address the underlying
ischemia.
Page 4
