1. A patient with deep vein thrombosis (DVT) is started on warfarin.
Which laboratory value should the nurse monitor to determine the
medication's effectiveness?
A. Platelet count
B. International Normalized Ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Hemoglobin
Answer: B. International Normalized Ratio (INR)
Rationale: INR is used to monitor the therapeutic effect of warfarin.
2. A patient presents with abdominal pain and a rigid abdomen. What
should the nurse do first?
A. Assess vital signs
B. Prepare the patient for surgery
C. Administer pain medication
D. Obtain a complete history
Answer: A. Assess vital signs
Rationale: A rigid abdomen may indicate peritonitis, which is life-
threatening. Vital signs help determine the patient’s stability.
,3. A nurse is preparing to administer an IV medication to a patient.
What is the nurse’s first action before administration?
A. Verify the patient’s allergies
B. Assess the IV site for patency
C. Check the medication dose and label
D. Wash hands thoroughly
Answer: D. Wash hands thoroughly
Rationale: Hand hygiene is the first and most crucial step in preventing
infection when administering any medication.
4. A nurse is caring for a patient with a cervical spine injury. Which
action should the nurse prioritize?
A. Monitor for bowel and bladder function
B. Ensure the patient is in a neutral position
C. Assess the patient's pain level
D. Administer a tetanus shot as prescribed
Answer: B. Ensure the patient is in a neutral position
Rationale: Ensuring proper spinal alignment is crucial in preventing
further injury and neurological damage.
5. The nurse is teaching a patient with hypertension about lifestyle
modifications. Which statement by the patient indicates an
understanding of the teaching?
, A. "I will increase my sodium intake to 4,500 mg daily."
B. "I will aim for at least 30 minutes of exercise most days."
C. "I will stop taking my blood pressure medication when I feel better."
D. "I will reduce my fluid intake to help lower my blood pressure."
Answer: B. "I will aim for at least 30 minutes of exercise most days."
Rationale: Regular physical activity helps lower blood pressure. Sodium
intake should be reduced, and medication should not be stopped
without a healthcare provider’s advice.
6. Which nursing action is essential when administering packed red
blood cells (PRBCs)?
A. Infuse the blood within 2 hours
B. Prime the tubing with dextrose 5%
C. Verify patient identity with another nurse
D. Monitor the patient every 30 minutes
Answer: C. Verify patient identity with another nurse
Rationale: Proper verification prevents transfusion reactions caused by
mismatched blood.
7. A nurse is assessing a patient with a suspected myocardial infarction.
Which finding is most indicative of an MI?
A. Pain radiating to the left arm and jaw
B. A persistent cough with yellow sputum
Which laboratory value should the nurse monitor to determine the
medication's effectiveness?
A. Platelet count
B. International Normalized Ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Hemoglobin
Answer: B. International Normalized Ratio (INR)
Rationale: INR is used to monitor the therapeutic effect of warfarin.
2. A patient presents with abdominal pain and a rigid abdomen. What
should the nurse do first?
A. Assess vital signs
B. Prepare the patient for surgery
C. Administer pain medication
D. Obtain a complete history
Answer: A. Assess vital signs
Rationale: A rigid abdomen may indicate peritonitis, which is life-
threatening. Vital signs help determine the patient’s stability.
,3. A nurse is preparing to administer an IV medication to a patient.
What is the nurse’s first action before administration?
A. Verify the patient’s allergies
B. Assess the IV site for patency
C. Check the medication dose and label
D. Wash hands thoroughly
Answer: D. Wash hands thoroughly
Rationale: Hand hygiene is the first and most crucial step in preventing
infection when administering any medication.
4. A nurse is caring for a patient with a cervical spine injury. Which
action should the nurse prioritize?
A. Monitor for bowel and bladder function
B. Ensure the patient is in a neutral position
C. Assess the patient's pain level
D. Administer a tetanus shot as prescribed
Answer: B. Ensure the patient is in a neutral position
Rationale: Ensuring proper spinal alignment is crucial in preventing
further injury and neurological damage.
5. The nurse is teaching a patient with hypertension about lifestyle
modifications. Which statement by the patient indicates an
understanding of the teaching?
, A. "I will increase my sodium intake to 4,500 mg daily."
B. "I will aim for at least 30 minutes of exercise most days."
C. "I will stop taking my blood pressure medication when I feel better."
D. "I will reduce my fluid intake to help lower my blood pressure."
Answer: B. "I will aim for at least 30 minutes of exercise most days."
Rationale: Regular physical activity helps lower blood pressure. Sodium
intake should be reduced, and medication should not be stopped
without a healthcare provider’s advice.
6. Which nursing action is essential when administering packed red
blood cells (PRBCs)?
A. Infuse the blood within 2 hours
B. Prime the tubing with dextrose 5%
C. Verify patient identity with another nurse
D. Monitor the patient every 30 minutes
Answer: C. Verify patient identity with another nurse
Rationale: Proper verification prevents transfusion reactions caused by
mismatched blood.
7. A nurse is assessing a patient with a suspected myocardial infarction.
Which finding is most indicative of an MI?
A. Pain radiating to the left arm and jaw
B. A persistent cough with yellow sputum
