, Question 1
Which action by the nurse best demonstrates the principle of nonmaleficence
when a patient with a do-not-resuscitate (DNR) order develops respiratory
distress?
A. Withholding all pain medication to avoid respiratory depression.
B. Administering prescribed morphine for comfort while monitoring
respiratory status.
C. Initiating CPR despite the DNR order.
D. Transferring the patient to the intensive care unit for intubation.
Correct Answer: B - Administering prescribed morphine for
comfort while monitoring respiratory status.
RATIONALE
Nonmaleficence requires avoiding harm; administering prescribed
morphine for comfort while monitoring is appropriate palliative care
and does not hasten death. Withholding pain medication (A) causes
unnecessary suffering, initiating CPR (C) violates the DNR order and
autonomy, and transfer for intubation (D) contradicts the DNR and
may cause harm.
Question 2
A nurse is calculating the dose of a continuous IV heparin infusion for a patient
with a pulmonary embolism. The order is 18 units/kg/hr. The patient weighs 70
kg. The pharmacy supplies heparin 25,000 units in 250 mL D5W. What is the
flow rate in mL/hr?
A. 12.6 mL/hr
B. 18.9 mL/hr
C. 25.2 mL/hr
D. 31.5 mL/hr
Correct Answer: A - 12.6 mL/hr
Page 2
, RATIONALE
Dose = 18 units/kg/hr × 70 kg = 1260 units/hr. Concentration = 25,000
units/250 mL = 100 units/mL. Flow rate = 1260 units/hr ÷ 100
units/mL = 12.6 mL/hr. Options B, C, and D result from calculation
errors.
Question 3
Which assessment finding is most concerning in a patient receiving a blood
transfusion?
A. Temperature increase from 37.0°C to 37.8°C after 15 minutes.
B. Urticaria and pruritus without fever.
C. Low back pain and dark urine.
D. Mild dyspnea relieved by sitting upright.
Correct Answer: C - Low back pain and dark urine.
RATIONALE
Low back pain and dark urine suggest an acute hemolytic transfusion
reaction, a life-threatening emergency requiring immediate cessation
of transfusion. A mild temperature rise (A) may be a febrile
non-hemolytic reaction, urticaria (B) indicates a mild allergic reaction,
and mild dyspnea (D) may be due to fluid overload or positioning, but
hemolysis is most critical.
Question 4
A nurse is prioritizing care for four patients. Which patient should the nurse
assess first after receiving handoff report?
A. A patient with chronic obstructive pulmonary disease who has an
oxygen saturation of 89% on 2 L nasal cannula.
B. A patient with diabetes who has a blood glucose of 250 mg/dL and is
due for insulin.
C. A patient with a new onset of chest pain and diaphoresis.
D. A patient with a fractured femur requesting pain medication.
Page 3
, Correct Answer: C - A patient with a new onset of chest pain and
diaphoresis.
RATIONALE
New chest pain with diaphoresis suggests acute coronary syndrome, a
life-threatening emergency requiring immediate assessment. Oxygen
saturation of 89% (A) is concerning but may be baseline for COPD;
glucose of 250 mg/dL (B) is not immediately life-threatening; pain
from fracture (D) is important but not the priority over cardiac
ischemia.
Question 5
A nurse is teaching a patient about newly prescribed warfarin. Which statement
by the patient indicates a need for further teaching?
A. I will use an electric razor to shave.
B. I will increase my intake of green leafy vegetables.
C. I will report any unusual bleeding or bruising.
D. I will keep my follow-up appointments for blood tests.
Correct Answer: B - I will increase my intake of green leafy
vegetables.
RATIONALE
Green leafy vegetables are high in vitamin K, which antagonizes
warfarin and can decrease its effectiveness. Patients should maintain
consistent intake, not increase it. Using an electric razor (A), reporting
bleeding (C), and keeping follow-up appointments (D) are correct
self-care measures.
Question 6
Which intervention is most appropriate for a patient with a new colostomy who
is experiencing skin breakdown around the stoma?
A. Apply alcohol-based skin barrier to the peristomal skin.
Page 4
Which action by the nurse best demonstrates the principle of nonmaleficence
when a patient with a do-not-resuscitate (DNR) order develops respiratory
distress?
A. Withholding all pain medication to avoid respiratory depression.
B. Administering prescribed morphine for comfort while monitoring
respiratory status.
C. Initiating CPR despite the DNR order.
D. Transferring the patient to the intensive care unit for intubation.
Correct Answer: B - Administering prescribed morphine for
comfort while monitoring respiratory status.
RATIONALE
Nonmaleficence requires avoiding harm; administering prescribed
morphine for comfort while monitoring is appropriate palliative care
and does not hasten death. Withholding pain medication (A) causes
unnecessary suffering, initiating CPR (C) violates the DNR order and
autonomy, and transfer for intubation (D) contradicts the DNR and
may cause harm.
Question 2
A nurse is calculating the dose of a continuous IV heparin infusion for a patient
with a pulmonary embolism. The order is 18 units/kg/hr. The patient weighs 70
kg. The pharmacy supplies heparin 25,000 units in 250 mL D5W. What is the
flow rate in mL/hr?
A. 12.6 mL/hr
B. 18.9 mL/hr
C. 25.2 mL/hr
D. 31.5 mL/hr
Correct Answer: A - 12.6 mL/hr
Page 2
, RATIONALE
Dose = 18 units/kg/hr × 70 kg = 1260 units/hr. Concentration = 25,000
units/250 mL = 100 units/mL. Flow rate = 1260 units/hr ÷ 100
units/mL = 12.6 mL/hr. Options B, C, and D result from calculation
errors.
Question 3
Which assessment finding is most concerning in a patient receiving a blood
transfusion?
A. Temperature increase from 37.0°C to 37.8°C after 15 minutes.
B. Urticaria and pruritus without fever.
C. Low back pain and dark urine.
D. Mild dyspnea relieved by sitting upright.
Correct Answer: C - Low back pain and dark urine.
RATIONALE
Low back pain and dark urine suggest an acute hemolytic transfusion
reaction, a life-threatening emergency requiring immediate cessation
of transfusion. A mild temperature rise (A) may be a febrile
non-hemolytic reaction, urticaria (B) indicates a mild allergic reaction,
and mild dyspnea (D) may be due to fluid overload or positioning, but
hemolysis is most critical.
Question 4
A nurse is prioritizing care for four patients. Which patient should the nurse
assess first after receiving handoff report?
A. A patient with chronic obstructive pulmonary disease who has an
oxygen saturation of 89% on 2 L nasal cannula.
B. A patient with diabetes who has a blood glucose of 250 mg/dL and is
due for insulin.
C. A patient with a new onset of chest pain and diaphoresis.
D. A patient with a fractured femur requesting pain medication.
Page 3
, Correct Answer: C - A patient with a new onset of chest pain and
diaphoresis.
RATIONALE
New chest pain with diaphoresis suggests acute coronary syndrome, a
life-threatening emergency requiring immediate assessment. Oxygen
saturation of 89% (A) is concerning but may be baseline for COPD;
glucose of 250 mg/dL (B) is not immediately life-threatening; pain
from fracture (D) is important but not the priority over cardiac
ischemia.
Question 5
A nurse is teaching a patient about newly prescribed warfarin. Which statement
by the patient indicates a need for further teaching?
A. I will use an electric razor to shave.
B. I will increase my intake of green leafy vegetables.
C. I will report any unusual bleeding or bruising.
D. I will keep my follow-up appointments for blood tests.
Correct Answer: B - I will increase my intake of green leafy
vegetables.
RATIONALE
Green leafy vegetables are high in vitamin K, which antagonizes
warfarin and can decrease its effectiveness. Patients should maintain
consistent intake, not increase it. Using an electric razor (A), reporting
bleeding (C), and keeping follow-up appointments (D) are correct
self-care measures.
Question 6
Which intervention is most appropriate for a patient with a new colostomy who
is experiencing skin breakdown around the stoma?
A. Apply alcohol-based skin barrier to the peristomal skin.
Page 4
