, Question 1
A patient with septic shock is receiving norepinephrine at 0.5 mcg/kg/min via a
central line. Which assessment finding most urgently indicates the need to
titrate the dose downward?
A. Mean arterial pressure of 68 mm Hg
B. Urine output of 0.5 mL/kg/hr
C. Cool, mottled extremities with capillary refill >3 seconds
D. Serum lactate trending down from 4.2 to 2.8 mmol/L
Correct Answer: C - Cool, mottled extremities with capillary
refill >3 seconds
RATIONALE
Cool, mottled extremities and delayed capillary refill indicate
excessive vasoconstriction from high-dose norepinephrine, risking
tissue ischemia; this warrants reducing the dose. A MAP of 68 is
within target, improving lactate and adequate urine output reflect
therapeutic response, not toxicity.
Question 2
A provider orders a medication that is a high-alert drug according to ISMP.
Which independent double-check process best prevents a catastrophic error?
A. One nurse verifies the order and administers while a second nurse
observes.
B. Two nurses separately calculate the dose, verify the pump, and
document the check before administration.
C. The pharmacist performs a final check and sends the medication in a
ready-to-administer form.
D. The nurse uses a barcode scanner and smart pump library to confirm
the five rights.
Correct Answer: B - Two nurses separately calculate the dose,
verify the pump, and document the check before administration.
Page 2
, RATIONALE
ISMP defines independent double-check as two clinicians separately
verifying the drug, dose, calculation, and pump settings without
knowledge of the other's result, then documenting. Observation alone
(A) is not independent, pharmacy preparation (C) doesn't replace
bedside verification, and barcode/ smart pump (D) are safeguards but
not a true independent double-check.
Question 3
A laboring patient at 41 weeks gestation has sudden severe abdominal pain, a
rigid uterus, and fetal bradycardia to 80 bpm. Which is the priority nursing
action?
A. Administer terbutaline to relax the uterus.
B. Prepare for immediate cesarean delivery.
C. Increase IV oxytocin to augment labor.
D. Perform a sterile vaginal exam to assess dilation.
Correct Answer: B - Prepare for immediate cesarean delivery.
RATIONALE
These findings suggest uterine rupture or placental abruption with
fetal compromise; the priority is emergent cesarean delivery to save
the fetus and mother. Terbutaline (A) is for tachysystole, oxytocin (C)
would worsen rupture, and vaginal exam (D) delays definitive
intervention.
Question 4
A child with acute lymphoblastic leukemia is receiving methotrexate. Which
laboratory value most specifically indicates methotrexate toxicity requiring
leucovorin rescue?
A. Serum creatinine 1.8 mg/dL
B. Methotrexate level 10 micromol/L at 48 hours
C. White blood cell count 2,000/mm³
Page 3
, D. Aspartate aminotransferase 120 U/L
Correct Answer: B - Methotrexate level 10 micromol/L at 48
hours
RATIONALE
Leucovorin rescue is guided by the methotrexate serum level at
specific time points; a level of 10 micromol/L at 48 hours is above the
therapeutic threshold and indicates delayed clearance requiring rescue.
Elevated creatinine (A) may cause delayed clearance, but the level
itself is the direct trigger; low WBC (C) and elevated AST (D) are
toxicities but not the specific trigger for leucovorin.
Question 5
A patient on clozapine for treatment-resistant schizophrenia presents with
fever, tachycardia, and a creatine kinase of 2,500 U/L. Which complication is
most likely?
A. Neuroleptic malignant syndrome
B. Serotonin syndrome
C. Agranulocytosis
D. Acute dystonia
Correct Answer: A - Neuroleptic malignant syndrome
RATIONALE
Neuroleptic malignant syndrome (NMS) is characterized by fever,
autonomic instability, and elevated creatine kinase due to muscle
rigidity; clozapine is an atypical antipsychotic but can still cause
NMS. Serotonin syndrome (B) is more associated with SSRIs and
presents with clonus and hyperreflexia; agranulocytosis (C) causes
infection without elevated CK; acute dystonia (D) involves muscle
spasms without fever or CK elevation.
Page 4
A patient with septic shock is receiving norepinephrine at 0.5 mcg/kg/min via a
central line. Which assessment finding most urgently indicates the need to
titrate the dose downward?
A. Mean arterial pressure of 68 mm Hg
B. Urine output of 0.5 mL/kg/hr
C. Cool, mottled extremities with capillary refill >3 seconds
D. Serum lactate trending down from 4.2 to 2.8 mmol/L
Correct Answer: C - Cool, mottled extremities with capillary
refill >3 seconds
RATIONALE
Cool, mottled extremities and delayed capillary refill indicate
excessive vasoconstriction from high-dose norepinephrine, risking
tissue ischemia; this warrants reducing the dose. A MAP of 68 is
within target, improving lactate and adequate urine output reflect
therapeutic response, not toxicity.
Question 2
A provider orders a medication that is a high-alert drug according to ISMP.
Which independent double-check process best prevents a catastrophic error?
A. One nurse verifies the order and administers while a second nurse
observes.
B. Two nurses separately calculate the dose, verify the pump, and
document the check before administration.
C. The pharmacist performs a final check and sends the medication in a
ready-to-administer form.
D. The nurse uses a barcode scanner and smart pump library to confirm
the five rights.
Correct Answer: B - Two nurses separately calculate the dose,
verify the pump, and document the check before administration.
Page 2
, RATIONALE
ISMP defines independent double-check as two clinicians separately
verifying the drug, dose, calculation, and pump settings without
knowledge of the other's result, then documenting. Observation alone
(A) is not independent, pharmacy preparation (C) doesn't replace
bedside verification, and barcode/ smart pump (D) are safeguards but
not a true independent double-check.
Question 3
A laboring patient at 41 weeks gestation has sudden severe abdominal pain, a
rigid uterus, and fetal bradycardia to 80 bpm. Which is the priority nursing
action?
A. Administer terbutaline to relax the uterus.
B. Prepare for immediate cesarean delivery.
C. Increase IV oxytocin to augment labor.
D. Perform a sterile vaginal exam to assess dilation.
Correct Answer: B - Prepare for immediate cesarean delivery.
RATIONALE
These findings suggest uterine rupture or placental abruption with
fetal compromise; the priority is emergent cesarean delivery to save
the fetus and mother. Terbutaline (A) is for tachysystole, oxytocin (C)
would worsen rupture, and vaginal exam (D) delays definitive
intervention.
Question 4
A child with acute lymphoblastic leukemia is receiving methotrexate. Which
laboratory value most specifically indicates methotrexate toxicity requiring
leucovorin rescue?
A. Serum creatinine 1.8 mg/dL
B. Methotrexate level 10 micromol/L at 48 hours
C. White blood cell count 2,000/mm³
Page 3
, D. Aspartate aminotransferase 120 U/L
Correct Answer: B - Methotrexate level 10 micromol/L at 48
hours
RATIONALE
Leucovorin rescue is guided by the methotrexate serum level at
specific time points; a level of 10 micromol/L at 48 hours is above the
therapeutic threshold and indicates delayed clearance requiring rescue.
Elevated creatinine (A) may cause delayed clearance, but the level
itself is the direct trigger; low WBC (C) and elevated AST (D) are
toxicities but not the specific trigger for leucovorin.
Question 5
A patient on clozapine for treatment-resistant schizophrenia presents with
fever, tachycardia, and a creatine kinase of 2,500 U/L. Which complication is
most likely?
A. Neuroleptic malignant syndrome
B. Serotonin syndrome
C. Agranulocytosis
D. Acute dystonia
Correct Answer: A - Neuroleptic malignant syndrome
RATIONALE
Neuroleptic malignant syndrome (NMS) is characterized by fever,
autonomic instability, and elevated creatine kinase due to muscle
rigidity; clozapine is an atypical antipsychotic but can still cause
NMS. Serotonin syndrome (B) is more associated with SSRIs and
presents with clonus and hyperreflexia; agranulocytosis (C) causes
infection without elevated CK; acute dystonia (D) involves muscle
spasms without fever or CK elevation.
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