, Question 1
A client receiving continuous IV heparin for venous thromboembolism has an
aPTT of 98 seconds (control 30 seconds) and new hematuria. Which action
should the nurse anticipate implementing first?
A. Administer vitamin K 10 mg IV push.
B. Stop the heparin infusion and prepare to administer protamine sulfate.
C. Continue the infusion and recheck aPTT in 6 hours.
D. Transfuse fresh frozen plasma and restart heparin at a lower rate.
Correct Answer: B - Stop the heparin infusion and prepare to
administer protamine sulfate.
RATIONALE
An aPTT >2.5 times control with bleeding indicates heparin-induced
coagulopathy; the infusion must be stopped and protamine sulfate (the
antidote) given. Vitamin K reverses warfarin, not heparin, and FFP is
not first-line for heparin reversal. Continuing the infusion risks
hemorrhage.
Question 2
Which instruction should the nurse provide to a client prescribed sublingual
nitroglycerin for stable angina?
A. Swallow the tablet with a full glass of water to enhance absorption.
B. Take one tablet every 5 minutes up to three doses; if pain persists, call
911.
C. Take the tablet only after the pain has subsided to prevent tolerance.
D. Store the tablets in a clear plastic pill organizer for easy access.
Correct Answer: B - Take one tablet every 5 minutes up to three
doses; if pain persists, call 911.
Page 2
, RATIONALE
Standard teaching is to take up to three SL nitroglycerin tablets 5
minutes apart; if chest pain persists after the first dose or worsens,
activate EMS. Swallowing SL tablets inactivates them, taking them
after pain subsides is illogical, and nitroglycerin must be stored in
dark glass to prevent degradation.
Question 3
A nurse is delegating care for a group of clients. Which task is appropriate to
delegate to the unlicensed assistive personnel (UAP)?
A. Reinforce teaching about a new colostomy appliance.
B. Obtain vital signs on a client 2 hours after a blood transfusion.
C. Administer a PRN oral analgesic to a client reporting pain.
D. Assess a client's surgical incision for signs of infection.
Correct Answer: B - Obtain vital signs on a client 2 hours after a
blood transfusion.
RATIONALE
Vital sign measurement on a stable client is within UAP scope;
however, the nurse must interpret the results, especially
post-transfusion. Teaching, medication administration, and assessment
are RN responsibilities and cannot be delegated to UAP.
Question 4
A postpartum client is receiving magnesium sulfate for preeclampsia. Which
finding requires immediate intervention?
A. Serum magnesium level of 5.8 mg/dL
B. Urine output of 25 mL/hr
C. Respiratory rate of 11 breaths/min
D. Deep tendon reflexes 2+
Correct Answer: C - Respiratory rate of 11 breaths/min
Page 3
A client receiving continuous IV heparin for venous thromboembolism has an
aPTT of 98 seconds (control 30 seconds) and new hematuria. Which action
should the nurse anticipate implementing first?
A. Administer vitamin K 10 mg IV push.
B. Stop the heparin infusion and prepare to administer protamine sulfate.
C. Continue the infusion and recheck aPTT in 6 hours.
D. Transfuse fresh frozen plasma and restart heparin at a lower rate.
Correct Answer: B - Stop the heparin infusion and prepare to
administer protamine sulfate.
RATIONALE
An aPTT >2.5 times control with bleeding indicates heparin-induced
coagulopathy; the infusion must be stopped and protamine sulfate (the
antidote) given. Vitamin K reverses warfarin, not heparin, and FFP is
not first-line for heparin reversal. Continuing the infusion risks
hemorrhage.
Question 2
Which instruction should the nurse provide to a client prescribed sublingual
nitroglycerin for stable angina?
A. Swallow the tablet with a full glass of water to enhance absorption.
B. Take one tablet every 5 minutes up to three doses; if pain persists, call
911.
C. Take the tablet only after the pain has subsided to prevent tolerance.
D. Store the tablets in a clear plastic pill organizer for easy access.
Correct Answer: B - Take one tablet every 5 minutes up to three
doses; if pain persists, call 911.
Page 2
, RATIONALE
Standard teaching is to take up to three SL nitroglycerin tablets 5
minutes apart; if chest pain persists after the first dose or worsens,
activate EMS. Swallowing SL tablets inactivates them, taking them
after pain subsides is illogical, and nitroglycerin must be stored in
dark glass to prevent degradation.
Question 3
A nurse is delegating care for a group of clients. Which task is appropriate to
delegate to the unlicensed assistive personnel (UAP)?
A. Reinforce teaching about a new colostomy appliance.
B. Obtain vital signs on a client 2 hours after a blood transfusion.
C. Administer a PRN oral analgesic to a client reporting pain.
D. Assess a client's surgical incision for signs of infection.
Correct Answer: B - Obtain vital signs on a client 2 hours after a
blood transfusion.
RATIONALE
Vital sign measurement on a stable client is within UAP scope;
however, the nurse must interpret the results, especially
post-transfusion. Teaching, medication administration, and assessment
are RN responsibilities and cannot be delegated to UAP.
Question 4
A postpartum client is receiving magnesium sulfate for preeclampsia. Which
finding requires immediate intervention?
A. Serum magnesium level of 5.8 mg/dL
B. Urine output of 25 mL/hr
C. Respiratory rate of 11 breaths/min
D. Deep tendon reflexes 2+
Correct Answer: C - Respiratory rate of 11 breaths/min
Page 3
