1. The nurse is caring for a patient with acute kidney injury. Which
electrolyte imbalance is most critical to address?
A. Sodium: 125 mEq/L
B. Potassium: 6.8 mEq/L
C. Calcium: 8.0 mg/dL
D. Phosphorus: 5.5 mg/dL
Answer and Rationale:
B. Potassium: 6.8 mEq/L
Rationale: Hyperkalemia can cause life-threatening cardiac arrhythmias
and requires immediate intervention.
2. A patient recovering from a thoracotomy has a respiratory rate of 28
breaths/min and is using accessory muscles to breathe. What is the
nurse’s first action?
A. Increase oxygen delivery.
B. Assess pain level and provide analgesia.
C. Perform a respiratory assessment.
D. Notify the healthcare provider.
Answer and Rationale:
C. Perform a respiratory assessment.
,Rationale: Identifying the underlying cause of respiratory distress is
essential before intervening.
3. A patient on telemetry exhibits a sudden onset of atrial fibrillation
with a ventricular rate of 140 bpm. What is the most appropriate initial
action by the nurse?
A. Administer an IV beta-blocker as prescribed.
B. Prepare the patient for cardioversion.
C. Assess the patient’s blood pressure and level of consciousness.
D. Notify the healthcare provider immediately.
Answer and Rationale:
C. Assess the patient’s blood pressure and level of consciousness.
Rationale: Assessment of hemodynamic stability is critical to determine
if the patient requires urgent intervention such as cardioversion or if
rate control measures can be pursued.
4. 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.
5. A patient with a tracheostomy is experiencing copious secretions and
a SpO2 of 85%. What is the nurse’s first action?
A. Increase supplemental oxygen.
B. Suction the tracheostomy tube.
C. Notify the healthcare provider.
D. Assess lung sounds and respiratory effort.
Answer and Rationale:
B. Suction the tracheostomy tube.
Rationale: Suctioning clears the airway and improves oxygenation in
patients with tracheostomies.
6. Which lab value is most concerning for a patient receiving heparin
therapy?
A. Platelet count: 95,000/μL
B. Hemoglobin: 12 g/dL
C. INR: 1.2
D. aPTT: 70 seconds
Answer and Rationale:
electrolyte imbalance is most critical to address?
A. Sodium: 125 mEq/L
B. Potassium: 6.8 mEq/L
C. Calcium: 8.0 mg/dL
D. Phosphorus: 5.5 mg/dL
Answer and Rationale:
B. Potassium: 6.8 mEq/L
Rationale: Hyperkalemia can cause life-threatening cardiac arrhythmias
and requires immediate intervention.
2. A patient recovering from a thoracotomy has a respiratory rate of 28
breaths/min and is using accessory muscles to breathe. What is the
nurse’s first action?
A. Increase oxygen delivery.
B. Assess pain level and provide analgesia.
C. Perform a respiratory assessment.
D. Notify the healthcare provider.
Answer and Rationale:
C. Perform a respiratory assessment.
,Rationale: Identifying the underlying cause of respiratory distress is
essential before intervening.
3. A patient on telemetry exhibits a sudden onset of atrial fibrillation
with a ventricular rate of 140 bpm. What is the most appropriate initial
action by the nurse?
A. Administer an IV beta-blocker as prescribed.
B. Prepare the patient for cardioversion.
C. Assess the patient’s blood pressure and level of consciousness.
D. Notify the healthcare provider immediately.
Answer and Rationale:
C. Assess the patient’s blood pressure and level of consciousness.
Rationale: Assessment of hemodynamic stability is critical to determine
if the patient requires urgent intervention such as cardioversion or if
rate control measures can be pursued.
4. 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.
5. A patient with a tracheostomy is experiencing copious secretions and
a SpO2 of 85%. What is the nurse’s first action?
A. Increase supplemental oxygen.
B. Suction the tracheostomy tube.
C. Notify the healthcare provider.
D. Assess lung sounds and respiratory effort.
Answer and Rationale:
B. Suction the tracheostomy tube.
Rationale: Suctioning clears the airway and improves oxygenation in
patients with tracheostomies.
6. Which lab value is most concerning for a patient receiving heparin
therapy?
A. Platelet count: 95,000/μL
B. Hemoglobin: 12 g/dL
C. INR: 1.2
D. aPTT: 70 seconds
Answer and Rationale:
