, Question 1
A patient with severe vomiting has an arterial blood gas: pH 7.48, PaCO2 40
mm Hg, HCO3- 30 mEq/L. Which compensatory mechanism is most likely
occurring?
A. Renal excretion of bicarbonate
B. Hyperventilation to blow off CO2
C. Renal retention of hydrogen ions
D. Increased lactic acid production
Correct Answer: A - Renal excretion of bicarbonate
RATIONALE
The ABG indicates metabolic alkalosis (elevated pH, elevated HCO3-
with normal PaCO2). Renal compensation for metabolic alkalosis
involves excreting excess bicarbonate and retaining hydrogen ions.
Hyperventilation would lower PaCO2, which is not present here.
Question 2
Which assessment finding is the earliest and most sensitive indicator of
increased intracranial pressure in a patient with a traumatic brain injury?
A. Decreased level of consciousness
B. Pupillary dilation
C. Cushing's triad
D. Decerebrate posturing
Correct Answer: A - Decreased level of consciousness
RATIONALE
A change in level of consciousness is the earliest and most reliable
indicator of rising ICP. Pupillary changes, Cushing's triad, and
posturing occur later as herniation progresses. Early recognition
allows timely intervention.
Page 2
, Question 3
A patient receiving intravenous heparin has an aPTT of 110 seconds
(therapeutic range 60-80 seconds). Which action should the nurse anticipate?
A. Administer protamine sulfate
B. Hold the heparin infusion and recheck aPTT
C. Increase the heparin infusion rate
D. Administer vitamin K
Correct Answer: B - Hold the heparin infusion and recheck aPTT
RATIONALE
An aPTT of 110 seconds is supratherapeutic, increasing bleeding risk.
The nurse should hold the infusion and recheck aPTT, then anticipate
dose adjustment. Protamine sulfate is the antidote but is typically
reserved for serious bleeding; vitamin K reverses warfarin, not
heparin.
Question 4
Which nursing action best prevents ventilator-associated pneumonia (VAP) in
an intubated patient?
A. Maintaining the head of the bed at 30-45 degrees
B. Suctioning the airway every 2 hours
C. Changing the ventilator circuit daily
D. Administering prophylactic antibiotics
Correct Answer: A - Maintaining the head of the bed at 30-45
degrees
RATIONALE
Elevating the head of the bed to 30-45 degrees reduces aspiration of
oropharyngeal secretions, a key VAP prevention strategy. Routine
suctioning, daily circuit changes, and prophylactic antibiotics are not
recommended and may increase risk.
Page 3
, Question 5
A patient is prescribed digoxin and furosemide. Which assessment finding
requires immediate intervention?
A. Heart rate of 58 beats/min
B. Serum potassium of 3.1 mEq/L
C. Blood pressure of 110/70 mm Hg
D. Urine output of 50 mL/hr
Correct Answer: B - Serum potassium of 3.1 mEq/L
RATIONALE
Furosemide causes potassium loss, and hypokalemia increases the risk
of digoxin toxicity. A potassium level of 3.1 mEq/L is dangerously
low and requires immediate correction. The other findings are within
acceptable ranges.
Question 6
Which instruction is most important for a patient starting rifampin for
tuberculosis?
A. Expect orange-red discoloration of body fluids
B. Take the medication with meals to reduce nausea
C. Avoid direct sunlight
D. Increase intake of vitamin K-rich foods
Correct Answer: A - Expect orange-red discoloration of body
fluids
RATIONALE
Rifampin commonly causes orange-red discoloration of urine, sweat,
and tears, which is harmless but should be expected. Taking with
meals can reduce absorption; sunlight avoidance and vitamin K are not
primary concerns.
Page 4
A patient with severe vomiting has an arterial blood gas: pH 7.48, PaCO2 40
mm Hg, HCO3- 30 mEq/L. Which compensatory mechanism is most likely
occurring?
A. Renal excretion of bicarbonate
B. Hyperventilation to blow off CO2
C. Renal retention of hydrogen ions
D. Increased lactic acid production
Correct Answer: A - Renal excretion of bicarbonate
RATIONALE
The ABG indicates metabolic alkalosis (elevated pH, elevated HCO3-
with normal PaCO2). Renal compensation for metabolic alkalosis
involves excreting excess bicarbonate and retaining hydrogen ions.
Hyperventilation would lower PaCO2, which is not present here.
Question 2
Which assessment finding is the earliest and most sensitive indicator of
increased intracranial pressure in a patient with a traumatic brain injury?
A. Decreased level of consciousness
B. Pupillary dilation
C. Cushing's triad
D. Decerebrate posturing
Correct Answer: A - Decreased level of consciousness
RATIONALE
A change in level of consciousness is the earliest and most reliable
indicator of rising ICP. Pupillary changes, Cushing's triad, and
posturing occur later as herniation progresses. Early recognition
allows timely intervention.
Page 2
, Question 3
A patient receiving intravenous heparin has an aPTT of 110 seconds
(therapeutic range 60-80 seconds). Which action should the nurse anticipate?
A. Administer protamine sulfate
B. Hold the heparin infusion and recheck aPTT
C. Increase the heparin infusion rate
D. Administer vitamin K
Correct Answer: B - Hold the heparin infusion and recheck aPTT
RATIONALE
An aPTT of 110 seconds is supratherapeutic, increasing bleeding risk.
The nurse should hold the infusion and recheck aPTT, then anticipate
dose adjustment. Protamine sulfate is the antidote but is typically
reserved for serious bleeding; vitamin K reverses warfarin, not
heparin.
Question 4
Which nursing action best prevents ventilator-associated pneumonia (VAP) in
an intubated patient?
A. Maintaining the head of the bed at 30-45 degrees
B. Suctioning the airway every 2 hours
C. Changing the ventilator circuit daily
D. Administering prophylactic antibiotics
Correct Answer: A - Maintaining the head of the bed at 30-45
degrees
RATIONALE
Elevating the head of the bed to 30-45 degrees reduces aspiration of
oropharyngeal secretions, a key VAP prevention strategy. Routine
suctioning, daily circuit changes, and prophylactic antibiotics are not
recommended and may increase risk.
Page 3
, Question 5
A patient is prescribed digoxin and furosemide. Which assessment finding
requires immediate intervention?
A. Heart rate of 58 beats/min
B. Serum potassium of 3.1 mEq/L
C. Blood pressure of 110/70 mm Hg
D. Urine output of 50 mL/hr
Correct Answer: B - Serum potassium of 3.1 mEq/L
RATIONALE
Furosemide causes potassium loss, and hypokalemia increases the risk
of digoxin toxicity. A potassium level of 3.1 mEq/L is dangerously
low and requires immediate correction. The other findings are within
acceptable ranges.
Question 6
Which instruction is most important for a patient starting rifampin for
tuberculosis?
A. Expect orange-red discoloration of body fluids
B. Take the medication with meals to reduce nausea
C. Avoid direct sunlight
D. Increase intake of vitamin K-rich foods
Correct Answer: A - Expect orange-red discoloration of body
fluids
RATIONALE
Rifampin commonly causes orange-red discoloration of urine, sweat,
and tears, which is harmless but should be expected. Taking with
meals can reduce absorption; sunlight avoidance and vitamin K are not
primary concerns.
Page 4
