, Question 1
A client with acute decompensated heart failure is prescribed intravenous
furosemide. Which assessment finding most urgently indicates a need to
withhold the dose and notify the provider?
A. Serum potassium 3.1 mEq/L
B. Urine output 40 mL/hr
C. Blood pressure 98/60 mm Hg
D. Serum sodium 134 mEq/L
Correct Answer: A - Serum potassium 3.1 mEq/L
RATIONALE
Loop diuretics cause potassium loss; a level <3.5 mEq/L increases risk
of digoxin toxicity and lethal dysrhythmias, so the dose should be held
and the provider notified. The other findings are either expected or not
immediately life-threatening.
Question 2
A nurse is calculating the dose of enoxaparin for a client with a creatinine
clearance of 22 mL/min. Which action is most appropriate?
A. Administer the prescribed dose as ordered.
B. Hold the dose and contact the provider for dose adjustment.
C. Administer half the prescribed dose and document.
D. Switch to unfractionated heparin without an order.
Correct Answer: B - Hold the dose and contact the provider for
dose adjustment.
RATIONALE
Enoxaparin is renally cleared; CrCl <30 mL/min requires dose
reduction or alternative therapy. The nurse must hold and clarify with
the provider, not independently adjust or substitute.
Page 2
, Question 3
A client with a new colostomy has a stoma that is dark purple and dry. Which
nursing action is the priority?
A. Apply a transparent film dressing over the stoma.
B. Notify the surgeon immediately.
C. Document the finding as normal.
D. Increase oral fluid intake.
Correct Answer: B - Notify the surgeon immediately.
RATIONALE
A dark purple, dry stoma indicates ischemia/necrosis, a surgical
emergency. Immediate provider notification is required; other actions
delay necessary intervention.
Question 4
A nurse is reviewing a medication administration record for a client with a
newly placed epidural catheter. Which medication should the nurse question?
A. Fentanyl 50 mcg IV every 2 hours PRN
B. Heparin 5000 units subcutaneously every 8 hours
C. Acetaminophen 650 mg PO every 6 hours PRN
D. Docusate sodium 100 mg PO daily
Correct Answer: B - Heparin 5000 units subcutaneously every 8
hours
RATIONALE
Heparin increases risk of epidural hematoma in a client with an
epidural catheter; it should be held and the provider notified. The other
medications are not contraindicated.
Page 3
, Question 5
A nurse is assessing a client with severe preeclampsia who is receiving
magnesium sulfate. Which finding indicates magnesium toxicity?
A. Respiratory rate 10/min
B. Deep tendon reflexes 2+
C. Urine output 50 mL/hr
D. Blood pressure 150/90 mm Hg
Correct Answer: A - Respiratory rate 10/min
RATIONALE
Magnesium toxicity manifests as respiratory depression (<12/min),
loss of deep tendon reflexes, and oliguria. The other findings are not
indicative of toxicity.
Question 6
A nurse is caring for a client with a traumatic brain injury who has an
intracranial pressure (ICP) monitor. Which intervention should the nurse
implement first when ICP increases to 22 mm Hg?
A. Administer mannitol 0.5 g/kg IV
B. Hyperventilate the client to a PaCO2 of 30 mm Hg
C. Elevate the head of the bed to 30 degrees
D. Perform a lumbar puncture
Correct Answer: C - Elevate the head of the bed to 30 degrees
RATIONALE
Elevating the head of the bed promotes venous drainage and reduces
ICP; it is a rapid, non-invasive first intervention. Mannitol and
hyperventilation are subsequent measures; lumbar puncture is
contraindicated.
Page 4
A client with acute decompensated heart failure is prescribed intravenous
furosemide. Which assessment finding most urgently indicates a need to
withhold the dose and notify the provider?
A. Serum potassium 3.1 mEq/L
B. Urine output 40 mL/hr
C. Blood pressure 98/60 mm Hg
D. Serum sodium 134 mEq/L
Correct Answer: A - Serum potassium 3.1 mEq/L
RATIONALE
Loop diuretics cause potassium loss; a level <3.5 mEq/L increases risk
of digoxin toxicity and lethal dysrhythmias, so the dose should be held
and the provider notified. The other findings are either expected or not
immediately life-threatening.
Question 2
A nurse is calculating the dose of enoxaparin for a client with a creatinine
clearance of 22 mL/min. Which action is most appropriate?
A. Administer the prescribed dose as ordered.
B. Hold the dose and contact the provider for dose adjustment.
C. Administer half the prescribed dose and document.
D. Switch to unfractionated heparin without an order.
Correct Answer: B - Hold the dose and contact the provider for
dose adjustment.
RATIONALE
Enoxaparin is renally cleared; CrCl <30 mL/min requires dose
reduction or alternative therapy. The nurse must hold and clarify with
the provider, not independently adjust or substitute.
Page 2
, Question 3
A client with a new colostomy has a stoma that is dark purple and dry. Which
nursing action is the priority?
A. Apply a transparent film dressing over the stoma.
B. Notify the surgeon immediately.
C. Document the finding as normal.
D. Increase oral fluid intake.
Correct Answer: B - Notify the surgeon immediately.
RATIONALE
A dark purple, dry stoma indicates ischemia/necrosis, a surgical
emergency. Immediate provider notification is required; other actions
delay necessary intervention.
Question 4
A nurse is reviewing a medication administration record for a client with a
newly placed epidural catheter. Which medication should the nurse question?
A. Fentanyl 50 mcg IV every 2 hours PRN
B. Heparin 5000 units subcutaneously every 8 hours
C. Acetaminophen 650 mg PO every 6 hours PRN
D. Docusate sodium 100 mg PO daily
Correct Answer: B - Heparin 5000 units subcutaneously every 8
hours
RATIONALE
Heparin increases risk of epidural hematoma in a client with an
epidural catheter; it should be held and the provider notified. The other
medications are not contraindicated.
Page 3
, Question 5
A nurse is assessing a client with severe preeclampsia who is receiving
magnesium sulfate. Which finding indicates magnesium toxicity?
A. Respiratory rate 10/min
B. Deep tendon reflexes 2+
C. Urine output 50 mL/hr
D. Blood pressure 150/90 mm Hg
Correct Answer: A - Respiratory rate 10/min
RATIONALE
Magnesium toxicity manifests as respiratory depression (<12/min),
loss of deep tendon reflexes, and oliguria. The other findings are not
indicative of toxicity.
Question 6
A nurse is caring for a client with a traumatic brain injury who has an
intracranial pressure (ICP) monitor. Which intervention should the nurse
implement first when ICP increases to 22 mm Hg?
A. Administer mannitol 0.5 g/kg IV
B. Hyperventilate the client to a PaCO2 of 30 mm Hg
C. Elevate the head of the bed to 30 degrees
D. Perform a lumbar puncture
Correct Answer: C - Elevate the head of the bed to 30 degrees
RATIONALE
Elevating the head of the bed promotes venous drainage and reduces
ICP; it is a rapid, non-invasive first intervention. Mannitol and
hyperventilation are subsequent measures; lumbar puncture is
contraindicated.
Page 4
