, Question 1
A client with type 1 diabetes mellitus is prescribed a continuous IV insulin
infusion. The pharmacy supplies 100 units of regular insulin in 100 mL of
0.9% sodium chloride. The provider orders the infusion at 7 units/hour. Using
an IV pump, what rate in mL/hour should the nurse program?
A. 0.7 mL/hour
B. 7 mL/hour
C. 10 mL/hour
D. 70 mL/hour
Correct Answer: B - 7 mL/hour
RATIONALE
The concentration is 100 units/100 mL = 1 unit/mL, so 7 units/hour
equals 7 mL/hour. Distractors reflect decimal errors or failure to use
the 1:1 concentration, and 70 mL/hour would deliver 70 units/hour, a
dangerous overdose.
Question 2
A client in the second stage of labor suddenly develops persistent fetal
bradycardia with a category III tracing. After repositioning and administering
oxygen, which action should the nurse anticipate next according to ACOG and
AWHONN guidelines?
A. Prepare for immediate cesarean birth if the tracing does not resolve.
B. Increase the oxytocin infusion to hasten delivery.
C. Administer a tocolytic and continue monitoring.
D. Document the finding as a normal variant and reassess in 30 minutes.
Correct Answer: A - Prepare for immediate cesarean birth if the
tracing does not resolve.
Page 2
, RATIONALE
Category III tracings with persistent bradycardia unresponsive to
intrauterine resuscitation require preparation for expedited delivery,
often cesarean. Oxytocin would worsen the pattern; tocolytics are for
tachysystole, and a category III tracing is not a normal variant.
Question 3
Which assessment finding in a client receiving lithium carbonate therapy for
bipolar disorder requires immediate intervention?
A. Serum lithium level of 1.1 mEq/L
B. Fine hand tremor and increased thirst
C. Coarse tremor, ataxia, and vomiting
D. Weight gain of 2 kg over one month
Correct Answer: C - Coarse tremor, ataxia, and vomiting
RATIONALE
Coarse tremor, ataxia, and vomiting indicate moderate-to-severe
lithium toxicity (levels typically >1.5 mEq/L) and require immediate
intervention. A level of 1.1 mEq/L is therapeutic; fine tremor and
thirst are common side effects; weight gain is not an emergency.
Question 4
A client with a new colostomy has a stoma that is dark purple and dry, with no
output for 12 hours. Which nursing action is the priority?
A. Apply a pouch and document the findings.
B. Notify the provider immediately.
C. Irrigate the stoma with warm saline.
D. Apply petroleum jelly to the stoma.
Correct Answer: B - Notify the provider immediately.
Page 3
A client with type 1 diabetes mellitus is prescribed a continuous IV insulin
infusion. The pharmacy supplies 100 units of regular insulin in 100 mL of
0.9% sodium chloride. The provider orders the infusion at 7 units/hour. Using
an IV pump, what rate in mL/hour should the nurse program?
A. 0.7 mL/hour
B. 7 mL/hour
C. 10 mL/hour
D. 70 mL/hour
Correct Answer: B - 7 mL/hour
RATIONALE
The concentration is 100 units/100 mL = 1 unit/mL, so 7 units/hour
equals 7 mL/hour. Distractors reflect decimal errors or failure to use
the 1:1 concentration, and 70 mL/hour would deliver 70 units/hour, a
dangerous overdose.
Question 2
A client in the second stage of labor suddenly develops persistent fetal
bradycardia with a category III tracing. After repositioning and administering
oxygen, which action should the nurse anticipate next according to ACOG and
AWHONN guidelines?
A. Prepare for immediate cesarean birth if the tracing does not resolve.
B. Increase the oxytocin infusion to hasten delivery.
C. Administer a tocolytic and continue monitoring.
D. Document the finding as a normal variant and reassess in 30 minutes.
Correct Answer: A - Prepare for immediate cesarean birth if the
tracing does not resolve.
Page 2
, RATIONALE
Category III tracings with persistent bradycardia unresponsive to
intrauterine resuscitation require preparation for expedited delivery,
often cesarean. Oxytocin would worsen the pattern; tocolytics are for
tachysystole, and a category III tracing is not a normal variant.
Question 3
Which assessment finding in a client receiving lithium carbonate therapy for
bipolar disorder requires immediate intervention?
A. Serum lithium level of 1.1 mEq/L
B. Fine hand tremor and increased thirst
C. Coarse tremor, ataxia, and vomiting
D. Weight gain of 2 kg over one month
Correct Answer: C - Coarse tremor, ataxia, and vomiting
RATIONALE
Coarse tremor, ataxia, and vomiting indicate moderate-to-severe
lithium toxicity (levels typically >1.5 mEq/L) and require immediate
intervention. A level of 1.1 mEq/L is therapeutic; fine tremor and
thirst are common side effects; weight gain is not an emergency.
Question 4
A client with a new colostomy has a stoma that is dark purple and dry, with no
output for 12 hours. Which nursing action is the priority?
A. Apply a pouch and document the findings.
B. Notify the provider immediately.
C. Irrigate the stoma with warm saline.
D. Apply petroleum jelly to the stoma.
Correct Answer: B - Notify the provider immediately.
Page 3
