, Question 1
A patient with acute decompensated heart failure is prescribed IV furosemide.
Which assessment finding indicates the most immediate risk requiring
intervention?
A. Serum potassium of 3.1 mEq/L
B. Urine output of 50 mL/hr
C. Blood pressure of 108/68 mm Hg
D. Respiratory rate of 22 breaths/min
Correct Answer: A - Serum potassium of 3.1 mEq/L
RATIONALE
Loop diuretics like furosemide cause significant potassium loss, and
hypokalemia increases the risk of fatal dysrhythmias. The other
findings are either expected or not immediately life-threatening. Urine
output and blood pressure are acceptable, and mild tachypnea is
common in heart failure.
Question 2
Which instruction should the nurse include when teaching a patient about
newly prescribed warfarin?
A. Increase intake of leafy green vegetables to stabilize INR.
B. Use a soft-bristled toothbrush and electric razor.
C. Take ibuprofen for headaches instead of acetaminophen.
D. Double the dose if a dose is missed.
Correct Answer: B - Use a soft-bristled toothbrush and electric
razor.
Page 2
, RATIONALE
Warfarin increases bleeding risk, so measures to prevent
trauma-induced bleeding are essential. Leafy greens contain vitamin
K, which antagonizes warfarin and should be kept consistent, not
increased. Ibuprofen increases bleeding risk and should be avoided;
missed doses should not be doubled.
Question 3
A nurse is caring for a patient with a new colostomy. Which statement by the
patient indicates a need for further teaching?
A. I will avoid eating foods that cause gas, like broccoli.
B. I should empty the pouch when it is one-third full.
C. I can use a pouch deodorant to reduce odor.
D. I will change the pouch every 7 days.
Correct Answer: D - I will change the pouch every 7 days.
RATIONALE
Colostomy pouches typically need to be changed every 3 to 7 days,
but the skin barrier should be changed every 1 to 3 days or when it
leaks. Waiting 7 days may lead to skin breakdown and leakage. The
other statements are correct: avoiding gas-forming foods, emptying at
one-third full, and using deodorants are appropriate.
Question 4
The nurse is reviewing laboratory results for a patient receiving heparin
infusion. Which finding requires immediate notification of the provider?
A. aPTT of 45 seconds
B. Platelet count of 150,000/mm³
C. Hemoglobin of 14 g/dL
D. INR of 1.0
Correct Answer: A - aPTT of 45 seconds
Page 3
A patient with acute decompensated heart failure is prescribed IV furosemide.
Which assessment finding indicates the most immediate risk requiring
intervention?
A. Serum potassium of 3.1 mEq/L
B. Urine output of 50 mL/hr
C. Blood pressure of 108/68 mm Hg
D. Respiratory rate of 22 breaths/min
Correct Answer: A - Serum potassium of 3.1 mEq/L
RATIONALE
Loop diuretics like furosemide cause significant potassium loss, and
hypokalemia increases the risk of fatal dysrhythmias. The other
findings are either expected or not immediately life-threatening. Urine
output and blood pressure are acceptable, and mild tachypnea is
common in heart failure.
Question 2
Which instruction should the nurse include when teaching a patient about
newly prescribed warfarin?
A. Increase intake of leafy green vegetables to stabilize INR.
B. Use a soft-bristled toothbrush and electric razor.
C. Take ibuprofen for headaches instead of acetaminophen.
D. Double the dose if a dose is missed.
Correct Answer: B - Use a soft-bristled toothbrush and electric
razor.
Page 2
, RATIONALE
Warfarin increases bleeding risk, so measures to prevent
trauma-induced bleeding are essential. Leafy greens contain vitamin
K, which antagonizes warfarin and should be kept consistent, not
increased. Ibuprofen increases bleeding risk and should be avoided;
missed doses should not be doubled.
Question 3
A nurse is caring for a patient with a new colostomy. Which statement by the
patient indicates a need for further teaching?
A. I will avoid eating foods that cause gas, like broccoli.
B. I should empty the pouch when it is one-third full.
C. I can use a pouch deodorant to reduce odor.
D. I will change the pouch every 7 days.
Correct Answer: D - I will change the pouch every 7 days.
RATIONALE
Colostomy pouches typically need to be changed every 3 to 7 days,
but the skin barrier should be changed every 1 to 3 days or when it
leaks. Waiting 7 days may lead to skin breakdown and leakage. The
other statements are correct: avoiding gas-forming foods, emptying at
one-third full, and using deodorants are appropriate.
Question 4
The nurse is reviewing laboratory results for a patient receiving heparin
infusion. Which finding requires immediate notification of the provider?
A. aPTT of 45 seconds
B. Platelet count of 150,000/mm³
C. Hemoglobin of 14 g/dL
D. INR of 1.0
Correct Answer: A - aPTT of 45 seconds
Page 3
