, Question 1
A nurse is preparing to administer a high-risk medication via a central venous
catheter. Which action best demonstrates the principle of 'right route' in the
context of the five rights of medication administration?
A. Verifying the catheter tip location on chest X-ray before
administration.
B. Confirming the medication is compatible with the catheter material.
C. Checking that the prescribed route matches the patient's current venous
access.
D. Ensuring the medication is administered at the prescribed time.
Correct Answer: C - Checking that the prescribed route matches
the patient's current venous access.
RATIONALE
The 'right route' requires confirming the prescribed route aligns with
the patient's actual access (e.g., central line vs. peripheral). Option A
addresses catheter placement verification, which is part of preparation
but not the right route itself. Option B relates to compatibility, and
Option D refers to the 'right time'.
Question 2
A patient with a history of heart failure is prescribed furosemide 40 mg IV
push. Which assessment finding would cause the nurse to withhold the dose
and contact the provider?
A. Serum potassium of 3.1 mEq/L
B. Blood pressure of 118/72 mm Hg
C. Urine output of 50 mL/hr
D. Heart rate of 88 beats/min
Correct Answer: A - Serum potassium of 3.1 mEq/L
Page 2
, RATIONALE
Furosemide is a loop diuretic that can cause hypokalemia; a potassium
level of 3.1 mEq/L is below normal (3.5-5.0) and increases risk of
dysrhythmias. The other findings are within normal limits and do not
contraindicate administration.
Question 3
A nurse is caring for a patient with active pulmonary tuberculosis. Which type
of isolation precautions should be implemented?
A. Standard precautions only
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
Correct Answer: D - Airborne precautions
RATIONALE
Tuberculosis is transmitted via airborne droplet nuclei, requiring
airborne precautions (N95 respirator, negative-pressure room).
Contact precautions are for direct/indirect contact, and droplet
precautions are for larger droplets (e.g., influenza). Standard
precautions alone are insufficient.
Question 4
A patient is admitted with severe dehydration. Which IV solution would the
nurse anticipate as the initial fluid replacement?
A. 0.45% sodium chloride (half-normal saline)
B. Lactated Ringer's solution
C. 5% dextrose in water (D5W)
D. 0.9% sodium chloride (normal saline)
Correct Answer: D - 0.9% sodium chloride (normal saline)
Page 3
, RATIONALE
Isotonic 0.9% sodium chloride is the initial fluid of choice for severe
dehydration to expand intravascular volume rapidly. Hypotonic
solutions like 0.45% NaCl or D5W do not stay in the vascular space
and can worsen hypotension. Lactated Ringer's is also isotonic but is
often used for surgical fluid replacement; normal saline is preferred
for initial resuscitation in many protocols.
Question 5
A nurse is reviewing a medication order for a patient with renal failure. Which
principle should guide the nurse's decision to question the order?
A. Medications are primarily excreted by the kidneys, so doses may need
adjustment.
B. Renal failure increases the risk of drug toxicity due to impaired
clearance.
C. The patient may require higher doses to achieve therapeutic effect.
D. Renal failure does not affect medication metabolism.
Correct Answer: B - Renal failure increases the risk of drug
toxicity due to impaired clearance.
RATIONALE
Renal impairment reduces clearance of renally excreted drugs,
increasing risk of toxicity; doses often need reduction. Option A is
true but less specific to the nurse's action; Option C is incorrect (doses
usually need decrease, not increase). Option D is false.
Question 6
A patient is scheduled for surgery and asks the nurse about advance directives.
Which statement by the nurse is most accurate?
A. Advance directives are only for terminally ill patients.
B. The Patient Self-Determination Act requires hospitals to ask about
advance directives on admission.
Page 4
A nurse is preparing to administer a high-risk medication via a central venous
catheter. Which action best demonstrates the principle of 'right route' in the
context of the five rights of medication administration?
A. Verifying the catheter tip location on chest X-ray before
administration.
B. Confirming the medication is compatible with the catheter material.
C. Checking that the prescribed route matches the patient's current venous
access.
D. Ensuring the medication is administered at the prescribed time.
Correct Answer: C - Checking that the prescribed route matches
the patient's current venous access.
RATIONALE
The 'right route' requires confirming the prescribed route aligns with
the patient's actual access (e.g., central line vs. peripheral). Option A
addresses catheter placement verification, which is part of preparation
but not the right route itself. Option B relates to compatibility, and
Option D refers to the 'right time'.
Question 2
A patient with a history of heart failure is prescribed furosemide 40 mg IV
push. Which assessment finding would cause the nurse to withhold the dose
and contact the provider?
A. Serum potassium of 3.1 mEq/L
B. Blood pressure of 118/72 mm Hg
C. Urine output of 50 mL/hr
D. Heart rate of 88 beats/min
Correct Answer: A - Serum potassium of 3.1 mEq/L
Page 2
, RATIONALE
Furosemide is a loop diuretic that can cause hypokalemia; a potassium
level of 3.1 mEq/L is below normal (3.5-5.0) and increases risk of
dysrhythmias. The other findings are within normal limits and do not
contraindicate administration.
Question 3
A nurse is caring for a patient with active pulmonary tuberculosis. Which type
of isolation precautions should be implemented?
A. Standard precautions only
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
Correct Answer: D - Airborne precautions
RATIONALE
Tuberculosis is transmitted via airborne droplet nuclei, requiring
airborne precautions (N95 respirator, negative-pressure room).
Contact precautions are for direct/indirect contact, and droplet
precautions are for larger droplets (e.g., influenza). Standard
precautions alone are insufficient.
Question 4
A patient is admitted with severe dehydration. Which IV solution would the
nurse anticipate as the initial fluid replacement?
A. 0.45% sodium chloride (half-normal saline)
B. Lactated Ringer's solution
C. 5% dextrose in water (D5W)
D. 0.9% sodium chloride (normal saline)
Correct Answer: D - 0.9% sodium chloride (normal saline)
Page 3
, RATIONALE
Isotonic 0.9% sodium chloride is the initial fluid of choice for severe
dehydration to expand intravascular volume rapidly. Hypotonic
solutions like 0.45% NaCl or D5W do not stay in the vascular space
and can worsen hypotension. Lactated Ringer's is also isotonic but is
often used for surgical fluid replacement; normal saline is preferred
for initial resuscitation in many protocols.
Question 5
A nurse is reviewing a medication order for a patient with renal failure. Which
principle should guide the nurse's decision to question the order?
A. Medications are primarily excreted by the kidneys, so doses may need
adjustment.
B. Renal failure increases the risk of drug toxicity due to impaired
clearance.
C. The patient may require higher doses to achieve therapeutic effect.
D. Renal failure does not affect medication metabolism.
Correct Answer: B - Renal failure increases the risk of drug
toxicity due to impaired clearance.
RATIONALE
Renal impairment reduces clearance of renally excreted drugs,
increasing risk of toxicity; doses often need reduction. Option A is
true but less specific to the nurse's action; Option C is incorrect (doses
usually need decrease, not increase). Option D is false.
Question 6
A patient is scheduled for surgery and asks the nurse about advance directives.
Which statement by the nurse is most accurate?
A. Advance directives are only for terminally ill patients.
B. The Patient Self-Determination Act requires hospitals to ask about
advance directives on admission.
Page 4
