, Question 1
A patient with acute decompensated heart failure is receiving IV furosemide.
Which assessment finding most urgently indicates a need to hold the dose and
notify the provider?
A. Serum potassium 3.1 mEq/L with new U waves on ECG
B. Urine output 40 mL/hr with specific gravity 1.020
C. Blood pressure 106/68 mm Hg with mild dizziness on standing
D. Weight loss of 1.2 kg over 24 hours
Correct Answer: A - Serum potassium 3.1 mEq/L with new U
waves on ECG
RATIONALE
Loop diuretics cause hypokalemia; a K+ of 3.1 with U waves signals
dangerous cardiac irritability and risk for dysrhythmias, requiring
holding the dose and replacement. The other findings are expected
therapeutic effects or mild, non-urgent side effects.
Question 2
A patient with type 1 diabetes on an insulin pump develops nausea, abdominal
pain, and Kussmaul respirations. Blood glucose is 412 mg/dL, pH 7.12, HCO3
8 mEq/L, and beta-hydroxybutyrate is elevated. Which action should the nurse
anticipate first?
A. Administer a 1-L bolus of 0.9% sodium chloride
B. Give subcutaneous insulin glargine 20 units
C. Initiate sodium bicarbonate infusion
D. Place the patient on a bicarbonate-based CRRT circuit
Correct Answer: A - Administer a 1-L bolus of 0.9% sodium
chloride
Page 2
, RATIONALE
DKA management begins with aggressive isotonic fluid resuscitation
to restore intravascular volume and renal perfusion. Subcutaneous
long-acting insulin is too slow; bicarbonate is reserved for pH <6.9;
CRRT is not indicated for uncomplicated DKA.
Question 3
A patient with an acute ischemic stroke is being evaluated for IV thrombolytic
therapy. Which finding would be an absolute contraindication to alteplase?
A. Blood pressure 178/102 mm Hg
B. Platelet count 185,000/mm³
C. INR 1.1
D. History of intracranial hemorrhage 2 years ago
Correct Answer: D - History of intracranial hemorrhage 2 years
ago
RATIONALE
Any prior intracranial hemorrhage is an absolute contraindication to
alteplase due to prohibitive risk of recurrent bleeding. Blood pressure
>185/110 is a relative contraindication requiring correction; normal
platelets and INR are not contraindications.
Question 4
A patient with chronic kidney disease stage 5 develops a serum potassium of
6.8 mEq/L with peaked T waves. Which intervention should the nurse
anticipate as the priority?
A. Administer sodium polystyrene sulfonate orally
B. Give IV calcium gluconate
C. Initiate regular insulin with dextrose infusion
D. Prepare for emergent hemodialysis
Correct Answer: B - Give IV calcium gluconate
Page 3
, RATIONALE
IV calcium gluconate is the immediate priority to stabilize myocardial
cell membranes and prevent lethal dysrhythmias while other measures
take effect. Insulin/dextrose and dialysis shift or remove potassium but
do not provide immediate cardiac protection.
Question 5
A patient with a traumatic brain injury has an ICP monitor reading 22 mm Hg.
Which nursing action is most appropriate to reduce ICP?
A. Cluster nursing care to allow uninterrupted rest
B. Maintain the head of bed flat to promote cerebral perfusion
C. Hyperventilate the patient to a PaCO2 of 25 mm Hg
D. Administer IV mannitol 0.25 g/kg bolus
Correct Answer: A - Cluster nursing care to allow uninterrupted
rest
RATIONALE
Clustering care minimizes stimulation and prevents spikes in ICP. Flat
positioning increases ICP; hyperventilation to PaCO2 <30 is only a
temporizing measure for herniation; mannitol is used but not as a
first-line independent nursing action without orders.
Question 6
A patient on mechanical ventilation with ARDS has the following settings:
FiO2 0.8, PEEP 14 cm H2O, tidal volume 6 mL/kg predicted body weight,
plateau pressure 28 cm H2O. Which parameter should the nurse monitor most
closely to prevent ventilator-induced lung injury?
A. Peak inspiratory pressure
B. Plateau pressure
C. Minute ventilation
D. Auto-PEEP
Page 4
A patient with acute decompensated heart failure is receiving IV furosemide.
Which assessment finding most urgently indicates a need to hold the dose and
notify the provider?
A. Serum potassium 3.1 mEq/L with new U waves on ECG
B. Urine output 40 mL/hr with specific gravity 1.020
C. Blood pressure 106/68 mm Hg with mild dizziness on standing
D. Weight loss of 1.2 kg over 24 hours
Correct Answer: A - Serum potassium 3.1 mEq/L with new U
waves on ECG
RATIONALE
Loop diuretics cause hypokalemia; a K+ of 3.1 with U waves signals
dangerous cardiac irritability and risk for dysrhythmias, requiring
holding the dose and replacement. The other findings are expected
therapeutic effects or mild, non-urgent side effects.
Question 2
A patient with type 1 diabetes on an insulin pump develops nausea, abdominal
pain, and Kussmaul respirations. Blood glucose is 412 mg/dL, pH 7.12, HCO3
8 mEq/L, and beta-hydroxybutyrate is elevated. Which action should the nurse
anticipate first?
A. Administer a 1-L bolus of 0.9% sodium chloride
B. Give subcutaneous insulin glargine 20 units
C. Initiate sodium bicarbonate infusion
D. Place the patient on a bicarbonate-based CRRT circuit
Correct Answer: A - Administer a 1-L bolus of 0.9% sodium
chloride
Page 2
, RATIONALE
DKA management begins with aggressive isotonic fluid resuscitation
to restore intravascular volume and renal perfusion. Subcutaneous
long-acting insulin is too slow; bicarbonate is reserved for pH <6.9;
CRRT is not indicated for uncomplicated DKA.
Question 3
A patient with an acute ischemic stroke is being evaluated for IV thrombolytic
therapy. Which finding would be an absolute contraindication to alteplase?
A. Blood pressure 178/102 mm Hg
B. Platelet count 185,000/mm³
C. INR 1.1
D. History of intracranial hemorrhage 2 years ago
Correct Answer: D - History of intracranial hemorrhage 2 years
ago
RATIONALE
Any prior intracranial hemorrhage is an absolute contraindication to
alteplase due to prohibitive risk of recurrent bleeding. Blood pressure
>185/110 is a relative contraindication requiring correction; normal
platelets and INR are not contraindications.
Question 4
A patient with chronic kidney disease stage 5 develops a serum potassium of
6.8 mEq/L with peaked T waves. Which intervention should the nurse
anticipate as the priority?
A. Administer sodium polystyrene sulfonate orally
B. Give IV calcium gluconate
C. Initiate regular insulin with dextrose infusion
D. Prepare for emergent hemodialysis
Correct Answer: B - Give IV calcium gluconate
Page 3
, RATIONALE
IV calcium gluconate is the immediate priority to stabilize myocardial
cell membranes and prevent lethal dysrhythmias while other measures
take effect. Insulin/dextrose and dialysis shift or remove potassium but
do not provide immediate cardiac protection.
Question 5
A patient with a traumatic brain injury has an ICP monitor reading 22 mm Hg.
Which nursing action is most appropriate to reduce ICP?
A. Cluster nursing care to allow uninterrupted rest
B. Maintain the head of bed flat to promote cerebral perfusion
C. Hyperventilate the patient to a PaCO2 of 25 mm Hg
D. Administer IV mannitol 0.25 g/kg bolus
Correct Answer: A - Cluster nursing care to allow uninterrupted
rest
RATIONALE
Clustering care minimizes stimulation and prevents spikes in ICP. Flat
positioning increases ICP; hyperventilation to PaCO2 <30 is only a
temporizing measure for herniation; mannitol is used but not as a
first-line independent nursing action without orders.
Question 6
A patient on mechanical ventilation with ARDS has the following settings:
FiO2 0.8, PEEP 14 cm H2O, tidal volume 6 mL/kg predicted body weight,
plateau pressure 28 cm H2O. Which parameter should the nurse monitor most
closely to prevent ventilator-induced lung injury?
A. Peak inspiratory pressure
B. Plateau pressure
C. Minute ventilation
D. Auto-PEEP
Page 4
