, Question 1
A charge nurse is assigning rooms for four clients. Which room assignment
requires immediate intervention to prevent a regulatory and safety violation?
A. A client with Clostridioides difficile in a room with a dedicated
bathroom and anteroom
B. A client with active pulmonary tuberculosis placed in a
negative-pressure room with an N95 mask for staff
C. A client with disseminated varicella-zoster placed in a
positive-pressure room with a susceptible pregnant nurse assigned
D. A client with methicillin-resistant Staphylococcus aureus in a private
room with contact precautions
Correct Answer: C - A client with disseminated varicella-zoster
placed in a positive-pressure room with a susceptible pregnant
nurse assigned
RATIONALE
Disseminated varicella-zoster requires airborne precautions with
negative-pressure airflow; placing the client in a positive-pressure
room and assigning a susceptible pregnant nurse violates both
transmission-based precautions and maternal-fetal safety. Options A,
B, and D reflect correct isolation principles (C. difficile contact, TB
airborne negative pressure, MRSA contact). Positive-pressure rooms
are for immunocompromised protective environments, not airborne
infections.
Question 2
A provider orders heparin infusion at 18 units/kg/hr for a client weighing 82
kg. The pharmacy supplies 25,000 units in 500 mL D5W. What is the infusion
rate in mL/hr? (Round to the nearest whole number.)
A. 28 mL/hr
B. 30 mL/hr
C. 32 mL/hr
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, D. 25 mL/hr
Correct Answer: B - 30 mL/hr
RATIONALE
Dose = 18 units/kg/hr × 82 kg = 1,476 units/hr. Concentration =
25,000 units / 500 mL = 50 units/mL. Rate = 1,476 ÷ 50 = 29.52
mL/hr, rounded to 30 mL/hr. Options A, C, and D reflect calculation
errors in weight-based dosing or concentration conversion.
Question 3
A client with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding most urgently requires the nurse to withhold the dose and
notify the provider?
A. Serum potassium 3.1 mEq/L
B. Blood pressure 108/68 mm Hg
C. Urine output 40 mL/hr
D. Serum sodium 138 mEq/L
Correct Answer: A - Serum potassium 3.1 mEq/L
RATIONALE
Furosemide is a loop diuretic that causes potassium loss; a serum
potassium of 3.1 mEq/L places the client at risk for life-threatening
dysrhythmias, so the dose should be held and the provider notified.
Blood pressure 108/68 is low-normal but not an absolute hold, urine
output 40 mL/hr is adequate, and sodium 138 mEq/L is normal.
Question 4
A nurse is evaluating a client's understanding of lithium therapy. Which client
statement indicates a need for further teaching?
A. "I will maintain a consistent sodium intake and avoid drastic diet
changes."
B. "I will take ibuprofen for headaches instead of acetaminophen."
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, C. "I will report increased thirst, tremors, or vomiting to my provider."
D. "I will have my lithium level checked regularly, especially after dose
changes."
Correct Answer: B - "I will take ibuprofen for headaches instead
of acetaminophen."
RATIONALE
NSAIDs such as ibuprofen reduce renal lithium clearance and can
precipitate toxicity; acetaminophen is the safer analgesic. Consistent
sodium intake, recognizing early toxicity signs (thirst, tremors,
vomiting), and routine level monitoring are all correct
self-management behaviors.
Question 5
A client at 32 weeks gestation presents with painless, bright red vaginal
bleeding. Which action should the nurse take first?
A. Perform a sterile vaginal examination to determine dilation
B. Assess fetal heart rate and maternal vital signs, then notify the provider
C. Obtain a urine specimen for protein and glucose
D. Administer betamethasone as ordered before further assessment
Correct Answer: B - Assess fetal heart rate and maternal vital
signs, then notify the provider
RATIONALE
Painless bright red bleeding suggests placenta previa; digital vaginal
examination is contraindicated due to risk of hemorrhage. The priority
is maternal-fetal assessment (fetal heart tones, vital signs) followed by
provider notification. Betamethasone may be indicated for fetal lung
maturity but is not the first action before assessment.
Page 4
A charge nurse is assigning rooms for four clients. Which room assignment
requires immediate intervention to prevent a regulatory and safety violation?
A. A client with Clostridioides difficile in a room with a dedicated
bathroom and anteroom
B. A client with active pulmonary tuberculosis placed in a
negative-pressure room with an N95 mask for staff
C. A client with disseminated varicella-zoster placed in a
positive-pressure room with a susceptible pregnant nurse assigned
D. A client with methicillin-resistant Staphylococcus aureus in a private
room with contact precautions
Correct Answer: C - A client with disseminated varicella-zoster
placed in a positive-pressure room with a susceptible pregnant
nurse assigned
RATIONALE
Disseminated varicella-zoster requires airborne precautions with
negative-pressure airflow; placing the client in a positive-pressure
room and assigning a susceptible pregnant nurse violates both
transmission-based precautions and maternal-fetal safety. Options A,
B, and D reflect correct isolation principles (C. difficile contact, TB
airborne negative pressure, MRSA contact). Positive-pressure rooms
are for immunocompromised protective environments, not airborne
infections.
Question 2
A provider orders heparin infusion at 18 units/kg/hr for a client weighing 82
kg. The pharmacy supplies 25,000 units in 500 mL D5W. What is the infusion
rate in mL/hr? (Round to the nearest whole number.)
A. 28 mL/hr
B. 30 mL/hr
C. 32 mL/hr
Page 2
, D. 25 mL/hr
Correct Answer: B - 30 mL/hr
RATIONALE
Dose = 18 units/kg/hr × 82 kg = 1,476 units/hr. Concentration =
25,000 units / 500 mL = 50 units/mL. Rate = 1,476 ÷ 50 = 29.52
mL/hr, rounded to 30 mL/hr. Options A, C, and D reflect calculation
errors in weight-based dosing or concentration conversion.
Question 3
A client with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding most urgently requires the nurse to withhold the dose and
notify the provider?
A. Serum potassium 3.1 mEq/L
B. Blood pressure 108/68 mm Hg
C. Urine output 40 mL/hr
D. Serum sodium 138 mEq/L
Correct Answer: A - Serum potassium 3.1 mEq/L
RATIONALE
Furosemide is a loop diuretic that causes potassium loss; a serum
potassium of 3.1 mEq/L places the client at risk for life-threatening
dysrhythmias, so the dose should be held and the provider notified.
Blood pressure 108/68 is low-normal but not an absolute hold, urine
output 40 mL/hr is adequate, and sodium 138 mEq/L is normal.
Question 4
A nurse is evaluating a client's understanding of lithium therapy. Which client
statement indicates a need for further teaching?
A. "I will maintain a consistent sodium intake and avoid drastic diet
changes."
B. "I will take ibuprofen for headaches instead of acetaminophen."
Page 3
, C. "I will report increased thirst, tremors, or vomiting to my provider."
D. "I will have my lithium level checked regularly, especially after dose
changes."
Correct Answer: B - "I will take ibuprofen for headaches instead
of acetaminophen."
RATIONALE
NSAIDs such as ibuprofen reduce renal lithium clearance and can
precipitate toxicity; acetaminophen is the safer analgesic. Consistent
sodium intake, recognizing early toxicity signs (thirst, tremors,
vomiting), and routine level monitoring are all correct
self-management behaviors.
Question 5
A client at 32 weeks gestation presents with painless, bright red vaginal
bleeding. Which action should the nurse take first?
A. Perform a sterile vaginal examination to determine dilation
B. Assess fetal heart rate and maternal vital signs, then notify the provider
C. Obtain a urine specimen for protein and glucose
D. Administer betamethasone as ordered before further assessment
Correct Answer: B - Assess fetal heart rate and maternal vital
signs, then notify the provider
RATIONALE
Painless bright red bleeding suggests placenta previa; digital vaginal
examination is contraindicated due to risk of hemorrhage. The priority
is maternal-fetal assessment (fetal heart tones, vital signs) followed by
provider notification. Betamethasone may be indicated for fetal lung
maturity but is not the first action before assessment.
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