1. The nurse notes that a patient receiving a blood transfusion develops
a fever, chills, and low back pain. What is the nurse’s priority action?
A. Slow the infusion rate.
B. Stop the transfusion immediately.
C. Administer acetaminophen.
D. Notify the healthcare provider.
Answer and Rationale:
B. Stop the transfusion immediately.
Rationale: These symptoms indicate a possible transfusion reaction,
which requires stopping the transfusion to prevent further
complications.
2. A patient on warfarin therapy has an INR of 4.5. What is the nurse’s
priority intervention?
A. Notify the healthcare provider.
B. Administer vitamin K as prescribed.
C. Hold the next dose of warfarin.
D. Assess the patient for signs of bleeding.
Answer and Rationale:
D. Assess the patient for signs of bleeding.
,Rationale: An elevated INR increases the risk of bleeding, and
assessment ensures early detection of complications.
3. A progressive care nurse is caring for a patient with sepsis. Which
finding indicates the need for immediate intervention?
A. Blood pressure 90/60 mmHg
B. Heart rate 112 bpm
C. Lactate level 4 mmol/L
D. Temperature 38.5°C (101.3°F)
Answer and Rationale:
C. Lactate level 4 mmol/L
Rationale: A lactate level >2 mmol/L indicates tissue hypoperfusion
and possible organ dysfunction. Prompt interventions are needed to
address underlying sepsis.
4. A patient receiving amiodarone develops a persistent cough and
dyspnea. What should the nurse do first?
A. Discontinue the amiodarone.
B. Notify the healthcare provider.
C. Obtain a chest X-ray.
D. Assess oxygen saturation.
Answer and Rationale:
D. Assess oxygen saturation.
, Rationale: Pulmonary toxicity is a serious side effect of amiodarone.
Assessment of oxygen saturation helps determine the severity and
guides further actions.
5. A patient with end-stage renal disease reports severe itching. What
intervention is most appropriate?
A. Administer prescribed antihistamines.
B. Encourage increased water intake.
C. Monitor phosphorus levels.
D. Apply emollients to the skin.
Answer and Rationale:
C. Monitor phosphorus levels.
Rationale: Severe itching in renal patients is often due to
hyperphosphatemia. Addressing the cause is more effective than
symptom management alone.
6. A patient is receiving high-dose corticosteroids for acute
exacerbation of asthma. Which finding requires immediate action?
A. Blood glucose of 180 mg/dL
B. White blood cell count of 14,000/μL
C. Temperature of 101.5°F (38.6°C)
D. Heart rate of 92 bpm
Answer and Rationale:
a fever, chills, and low back pain. What is the nurse’s priority action?
A. Slow the infusion rate.
B. Stop the transfusion immediately.
C. Administer acetaminophen.
D. Notify the healthcare provider.
Answer and Rationale:
B. Stop the transfusion immediately.
Rationale: These symptoms indicate a possible transfusion reaction,
which requires stopping the transfusion to prevent further
complications.
2. A patient on warfarin therapy has an INR of 4.5. What is the nurse’s
priority intervention?
A. Notify the healthcare provider.
B. Administer vitamin K as prescribed.
C. Hold the next dose of warfarin.
D. Assess the patient for signs of bleeding.
Answer and Rationale:
D. Assess the patient for signs of bleeding.
,Rationale: An elevated INR increases the risk of bleeding, and
assessment ensures early detection of complications.
3. A progressive care nurse is caring for a patient with sepsis. Which
finding indicates the need for immediate intervention?
A. Blood pressure 90/60 mmHg
B. Heart rate 112 bpm
C. Lactate level 4 mmol/L
D. Temperature 38.5°C (101.3°F)
Answer and Rationale:
C. Lactate level 4 mmol/L
Rationale: A lactate level >2 mmol/L indicates tissue hypoperfusion
and possible organ dysfunction. Prompt interventions are needed to
address underlying sepsis.
4. A patient receiving amiodarone develops a persistent cough and
dyspnea. What should the nurse do first?
A. Discontinue the amiodarone.
B. Notify the healthcare provider.
C. Obtain a chest X-ray.
D. Assess oxygen saturation.
Answer and Rationale:
D. Assess oxygen saturation.
, Rationale: Pulmonary toxicity is a serious side effect of amiodarone.
Assessment of oxygen saturation helps determine the severity and
guides further actions.
5. A patient with end-stage renal disease reports severe itching. What
intervention is most appropriate?
A. Administer prescribed antihistamines.
B. Encourage increased water intake.
C. Monitor phosphorus levels.
D. Apply emollients to the skin.
Answer and Rationale:
C. Monitor phosphorus levels.
Rationale: Severe itching in renal patients is often due to
hyperphosphatemia. Addressing the cause is more effective than
symptom management alone.
6. A patient is receiving high-dose corticosteroids for acute
exacerbation of asthma. Which finding requires immediate action?
A. Blood glucose of 180 mg/dL
B. White blood cell count of 14,000/μL
C. Temperature of 101.5°F (38.6°C)
D. Heart rate of 92 bpm
Answer and Rationale:
