, Question 1
A patient receiving continuous IV heparin infusion has an aPTT of 95 seconds
(therapeutic range 60-80 seconds) and new hematuria. Which action should the
nurse anticipate?
A. Administer vitamin K subcutaneously.
B. Stop the infusion and prepare to administer protamine sulfate.
C. Decrease the infusion rate by 50% and recheck aPTT in 6 hours.
D. Continue the infusion and monitor for further bleeding.
Correct Answer: B - Stop the infusion and prepare to administer
protamine sulfate.
RATIONALE
An aPTT >80 seconds with bleeding indicates supratherapeutic
heparinization; the infusion must be stopped and protamine sulfate
given as the antidote. Vitamin K reverses warfarin, not heparin.
Decreasing the rate does not address active bleeding, and continuing
the infusion worsens risk.
Question 2
Which assessment finding is most concerning for a patient receiving a blood
transfusion 15 minutes after initiation?
A. Temperature 37.8°C (100°F) and mild chills.
B. Urticaria and pruritus on the trunk.
C. Blood pressure 90/50 mm Hg, heart rate 120 bpm, and flank pain.
D. Complaint of a metallic taste and mild nausea.
Correct Answer: C - Blood pressure 90/50 mm Hg, heart rate 120
bpm, and flank pain.
Page 2
, RATIONALE
Hypotension, tachycardia, and flank pain indicate an acute hemolytic
transfusion reaction, which is life-threatening and requires immediate
cessation. Urticaria suggests a mild allergic reaction; fever and chills
may be febrile non-hemolytic. Metallic taste is often a benign citrate
reaction.
Question 3
A patient with chronic kidney disease (CKD) has a serum potassium of 6.2
mEq/L and peaked T waves on ECG. Which intervention should the nurse
implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Administer intravenous calcium gluconate.
C. Administer regular insulin with dextrose IV.
D. Prepare for emergency hemodialysis.
Correct Answer: B - Administer intravenous calcium gluconate.
RATIONALE
Calcium gluconate stabilizes cardiac membranes immediately,
preventing fatal arrhythmias. Insulin/dextrose and Kayexalate shift or
eliminate potassium but have delayed onset. Dialysis is definitive but
not the first immediate action.
Question 4
Which statement by a patient scheduled for a colonoscopy with moderate
sedation indicates a need for further teaching?
A. I will drink only clear liquids the day before.
B. I can drive myself home after the procedure.
C. I should stop my blood thinners as instructed.
D. I will have someone stay with me for 24 hours.
Correct Answer: B - I can drive myself home after the procedure.
Page 3
, RATIONALE
Moderate sedation impairs judgment and reflexes; driving is unsafe.
Clear liquids, holding anticoagulants, and having a companion are
correct pre- and post-procedure instructions. The patient must not
drive.
Question 5
A patient with a new tracheostomy is being suctioned. Which technique is
most appropriate to prevent hypoxia?
A. Suction for 15 seconds continuously without interruption.
B. Hyperoxygenate with 100% oxygen before and after suctioning.
C. Instill 5 mL normal saline to loosen secretions before suctioning.
D. Use a suction catheter that occludes the airway completely.
Correct Answer: B - Hyperoxygenate with 100% oxygen before
and after suctioning.
RATIONALE
Hyperoxygenation prevents hypoxemia during suctioning. Suctioning
should not exceed 10-15 seconds, but continuous 15 seconds without
hyperoxygenation is unsafe. Routine saline instillation is no longer
recommended. The catheter should not occlude more than 50% of the
airway.
Question 6
A patient is prescribed 1,000 mL of 0.9% NaCl to infuse over 8 hours. The
drop factor is 15 gtt/mL. What is the flow rate in drops per minute? (Round to
the nearest whole number.)
A. 31 gtt/min
B. 42 gtt/min
C. 21 gtt/min
D. 63 gtt/min
Page 4
A patient receiving continuous IV heparin infusion has an aPTT of 95 seconds
(therapeutic range 60-80 seconds) and new hematuria. Which action should the
nurse anticipate?
A. Administer vitamin K subcutaneously.
B. Stop the infusion and prepare to administer protamine sulfate.
C. Decrease the infusion rate by 50% and recheck aPTT in 6 hours.
D. Continue the infusion and monitor for further bleeding.
Correct Answer: B - Stop the infusion and prepare to administer
protamine sulfate.
RATIONALE
An aPTT >80 seconds with bleeding indicates supratherapeutic
heparinization; the infusion must be stopped and protamine sulfate
given as the antidote. Vitamin K reverses warfarin, not heparin.
Decreasing the rate does not address active bleeding, and continuing
the infusion worsens risk.
Question 2
Which assessment finding is most concerning for a patient receiving a blood
transfusion 15 minutes after initiation?
A. Temperature 37.8°C (100°F) and mild chills.
B. Urticaria and pruritus on the trunk.
C. Blood pressure 90/50 mm Hg, heart rate 120 bpm, and flank pain.
D. Complaint of a metallic taste and mild nausea.
Correct Answer: C - Blood pressure 90/50 mm Hg, heart rate 120
bpm, and flank pain.
Page 2
, RATIONALE
Hypotension, tachycardia, and flank pain indicate an acute hemolytic
transfusion reaction, which is life-threatening and requires immediate
cessation. Urticaria suggests a mild allergic reaction; fever and chills
may be febrile non-hemolytic. Metallic taste is often a benign citrate
reaction.
Question 3
A patient with chronic kidney disease (CKD) has a serum potassium of 6.2
mEq/L and peaked T waves on ECG. Which intervention should the nurse
implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Administer intravenous calcium gluconate.
C. Administer regular insulin with dextrose IV.
D. Prepare for emergency hemodialysis.
Correct Answer: B - Administer intravenous calcium gluconate.
RATIONALE
Calcium gluconate stabilizes cardiac membranes immediately,
preventing fatal arrhythmias. Insulin/dextrose and Kayexalate shift or
eliminate potassium but have delayed onset. Dialysis is definitive but
not the first immediate action.
Question 4
Which statement by a patient scheduled for a colonoscopy with moderate
sedation indicates a need for further teaching?
A. I will drink only clear liquids the day before.
B. I can drive myself home after the procedure.
C. I should stop my blood thinners as instructed.
D. I will have someone stay with me for 24 hours.
Correct Answer: B - I can drive myself home after the procedure.
Page 3
, RATIONALE
Moderate sedation impairs judgment and reflexes; driving is unsafe.
Clear liquids, holding anticoagulants, and having a companion are
correct pre- and post-procedure instructions. The patient must not
drive.
Question 5
A patient with a new tracheostomy is being suctioned. Which technique is
most appropriate to prevent hypoxia?
A. Suction for 15 seconds continuously without interruption.
B. Hyperoxygenate with 100% oxygen before and after suctioning.
C. Instill 5 mL normal saline to loosen secretions before suctioning.
D. Use a suction catheter that occludes the airway completely.
Correct Answer: B - Hyperoxygenate with 100% oxygen before
and after suctioning.
RATIONALE
Hyperoxygenation prevents hypoxemia during suctioning. Suctioning
should not exceed 10-15 seconds, but continuous 15 seconds without
hyperoxygenation is unsafe. Routine saline instillation is no longer
recommended. The catheter should not occlude more than 50% of the
airway.
Question 6
A patient is prescribed 1,000 mL of 0.9% NaCl to infuse over 8 hours. The
drop factor is 15 gtt/mL. What is the flow rate in drops per minute? (Round to
the nearest whole number.)
A. 31 gtt/min
B. 42 gtt/min
C. 21 gtt/min
D. 63 gtt/min
Page 4
