, Question 1
Which assessment finding most urgently requires the practical nurse to notify
the provider for a client receiving continuous heparin infusion?
A. Platelet count 110,000/mm³ with new petechiae
B. aPTT 65 seconds (therapeutic range 1.5-2.5× control)
C. Hemoglobin 11.2 g/dL and hematocrit 34%
D. INR 1.1 with no signs of bleeding
Correct Answer: A - Platelet count 110,000/mm³ with new
petechiae
RATIONALE
Heparin-induced thrombocytopenia (HIT) is a life-threatening immune
reaction marked by a >50% platelet drop and thrombosis/bleeding; it
mandates immediate heparin discontinuation and provider notification.
The other options represent therapeutic or expected values without
acute danger.
Question 2
A client with severe preeclampsia is receiving magnesium sulfate. Which
finding indicates magnesium toxicity requiring immediate intervention?
A. Deep tendon reflexes 1+ and urine output 20 mL/hr
B. Respiratory rate 10/min and absent deep tendon reflexes
C. Blood pressure 148/92 mm Hg and headache
D. Serum magnesium level 5.5 mg/dL
Correct Answer: B - Respiratory rate 10/min and absent deep
tendon reflexes
RATIONALE
Magnesium toxicity first depresses deep tendon reflexes, then
respirations; RR <12 and absent DTRs signal impending respiratory
arrest requiring stop infusion and administer calcium gluconate. The
other findings are either expected or not indicative of toxicity.
Page 2
, Question 3
Which action by the practical nurse best demonstrates correct use of the SBAR
communication tool when reporting a client's deteriorating condition?
A. Stating the client's name, room number, and diagnosis before
describing the current vital signs
B. Providing a concise summary of the situation, background,
assessment, and a specific recommendation
C. Documenting the full shift assessment in the electronic record before
calling the provider
D. Delegating the call to the unlicensed assistive personnel to save time
Correct Answer: B - Providing a concise summary of the
situation, background, assessment, and a specific
recommendation
RATIONALE
SBAR structures communication as Situation, Background,
Assessment, and Recommendation, ensuring concise, complete
handoff. Option A omits assessment/recommendation; C delays care;
D exceeds UAP scope.
Question 4
A client is prescribed digoxin and furosemide. Which assessment finding most
suggests digoxin toxicity?
A. Heart rate 58 beats/min and nausea with visual halos
B. Blood pressure 118/76 mm Hg and dry mouth
C. Serum potassium 3.8 mEq/L and constipation
D. Weight loss of 1 kg since admission
Correct Answer: A - Heart rate 58 beats/min and nausea with
visual halos
Page 3
Which assessment finding most urgently requires the practical nurse to notify
the provider for a client receiving continuous heparin infusion?
A. Platelet count 110,000/mm³ with new petechiae
B. aPTT 65 seconds (therapeutic range 1.5-2.5× control)
C. Hemoglobin 11.2 g/dL and hematocrit 34%
D. INR 1.1 with no signs of bleeding
Correct Answer: A - Platelet count 110,000/mm³ with new
petechiae
RATIONALE
Heparin-induced thrombocytopenia (HIT) is a life-threatening immune
reaction marked by a >50% platelet drop and thrombosis/bleeding; it
mandates immediate heparin discontinuation and provider notification.
The other options represent therapeutic or expected values without
acute danger.
Question 2
A client with severe preeclampsia is receiving magnesium sulfate. Which
finding indicates magnesium toxicity requiring immediate intervention?
A. Deep tendon reflexes 1+ and urine output 20 mL/hr
B. Respiratory rate 10/min and absent deep tendon reflexes
C. Blood pressure 148/92 mm Hg and headache
D. Serum magnesium level 5.5 mg/dL
Correct Answer: B - Respiratory rate 10/min and absent deep
tendon reflexes
RATIONALE
Magnesium toxicity first depresses deep tendon reflexes, then
respirations; RR <12 and absent DTRs signal impending respiratory
arrest requiring stop infusion and administer calcium gluconate. The
other findings are either expected or not indicative of toxicity.
Page 2
, Question 3
Which action by the practical nurse best demonstrates correct use of the SBAR
communication tool when reporting a client's deteriorating condition?
A. Stating the client's name, room number, and diagnosis before
describing the current vital signs
B. Providing a concise summary of the situation, background,
assessment, and a specific recommendation
C. Documenting the full shift assessment in the electronic record before
calling the provider
D. Delegating the call to the unlicensed assistive personnel to save time
Correct Answer: B - Providing a concise summary of the
situation, background, assessment, and a specific
recommendation
RATIONALE
SBAR structures communication as Situation, Background,
Assessment, and Recommendation, ensuring concise, complete
handoff. Option A omits assessment/recommendation; C delays care;
D exceeds UAP scope.
Question 4
A client is prescribed digoxin and furosemide. Which assessment finding most
suggests digoxin toxicity?
A. Heart rate 58 beats/min and nausea with visual halos
B. Blood pressure 118/76 mm Hg and dry mouth
C. Serum potassium 3.8 mEq/L and constipation
D. Weight loss of 1 kg since admission
Correct Answer: A - Heart rate 58 beats/min and nausea with
visual halos
Page 3
