Question 1: A nurse is assessing a patient who has been receiving intravenous
furosemide for three days. Which assessment finding requires immediate
intervention?
A. Blood pressure 112/68 mm Hg
B. Serum potassium 2.8 mEq/L
C. Urine output 60 mL/hr
D. Weight loss of 1 kg
CORRECT ANSWER: B. Serum potassium 2.8 mEq/L
Rationale: Furosemide is a loop diuretic that causes significant potassium loss, and a
level of 2.8 mEq/L is critically low. Hypokalemia predisposes the patient to ventricular
dysrhythmias, muscle weakness, and ileus. Blood pressure of 112/68 mm Hg is
acceptable. Urine output of 60 mL/hr indicates adequate diuresis. A 1 kg weight loss
reflects appropriate fluid removal. Immediate potassium replacement and cardiac
monitoring are required.
Question 2: A nurse is preparing to administer digoxin to a patient with heart failure.
Which assessment finding should cause the nurse to withhold the medication?
A. Heart rate 52 beats/min
B. Blood pressure 128/76 mm Hg
C. Serum potassium 4.2 mEq/L
D. Digoxin level 1.2 ng/mL
CORRECT ANSWER: A. Heart rate 52 beats/min
Rationale: Digoxin slows cardiac conduction, and a heart rate below 60 beats/min in
adults warrants holding the dose. Blood pressure of 128/76 mm Hg is within normal
limits. Serum potassium of 4.2 mEq/L is normal and does not require holding. A digoxin
level of 1.2 ng/mL is therapeutic. Administering digoxin at this heart rate could cause
severe bradycardia or heart block.
Question 3: A patient is receiving heparin sodium via continuous intravenous
infusion. Which laboratory value should the nurse monitor to evaluate therapeutic
e ectiveness?
A. Prothrombin time
B. International normalized ratio
C. Activated partial thromboplastin time
D. Bleeding time
CORRECT ANSWER: C. Activated partial thromboplastin time
Rationale: Activated partial thromboplastin time measures the intrinsic coagulation
pathway and is the standard test for monitoring unfractionated heparin. Prothrombin
,time and international normalized ratio monitor warfarin therapy. Bleeding time
assesses platelet function, not heparin e ect. The therapeutic goal for heparin is an
aPTT of 1.5 to 2.5 times the control value. Monitoring prevents both bleeding and
thrombotic complications.
Question 4: A nurse is teaching a patient who is starting warfarin therapy. Which
statement by the patient indicates a need for further teaching?
A. "I will use an electric razor instead of a disposable one."
B. "I will increase my intake of spinach and kale."
C. "I will keep all follow-up appointments for blood tests."
D. "I will report any unusual bruising or bleeding."
CORRECT ANSWER: B. "I will increase my intake of spinach and kale."
Rationale: Spinach and kale are rich in vitamin K, which antagonizes warfarin and
reduces its anticoagulant e ect. Patients should maintain a consistent, not increased,
intake of vitamin K-rich foods. Using an electric razor reduces bleeding risk from nicks.
Keeping follow-up appointments for INR monitoring is essential. Reporting unusual
bruising or bleeding is appropriate. This statement indicates a misunderstanding
requiring correction.
Question 5: A nurse is caring for a patient with a new diagnosis of type 1 diabetes
mellitus. Which statement by the patient indicates correct understanding of insulin
administration?
A. "I will rotate injection sites within the same area."
B. "I will inject into the same spot each time."
C. "I will massage the site vigorously after injection."
D. "I will store my insulin in the freezer."
CORRECT ANSWER: A. "I will rotate injection sites within the same area."
Rationale: Rotating injection sites within the same anatomic area maintains consistent
absorption while preventing lipohypertrophy. Injecting into the same spot causes scar
tissue and erratic absorption. Vigorous massage increases absorption rate
unpredictably and causes bruising. Insulin must never be frozen because freezing
destroys its potency. Proper site rotation ensures reliable glycemic control.
Question 6: A nurse is assessing a patient with diabetic ketoacidosis. Which finding
is most consistent with this diagnosis?
A. Blood glucose 620 mg/dL with pH 7.25
B. Blood glucose 210 mg/dL with pH 7.48
C. Blood glucose 95 mg/dL with pH 7.38
D. Blood glucose 480 mg/dL with pH 7.42
,CORRECT ANSWER: A. Blood glucose 620 mg/dL with pH 7.25
Rationale: Diabetic ketoacidosis presents with marked hyperglycemia, metabolic
acidosis, and ketonemia. A glucose of 620 mg/dL with a pH of 7.25 reflects the
hyperglycemia and acidosis characteristic of DKA. Glucose of 210 mg/dL with pH 7.48
suggests alkalosis, not DKA. Glucose of 95 mg/dL is normal and inconsistent with DKA.
Glucose of 480 mg/dL with pH 7.42 lacks the acidosis required for DKA diagnosis.
Question 7: A nurse is reviewing laboratory values for a patient with chronic kidney
disease. Which finding requires immediate follow-up?
A. Serum potassium 6.4 mEq/L
B. Serum creatinine 3.2 mg/dL
C. Blood urea nitrogen 45 mg/dL
D. Hemoglobin 10.2 g/dL
CORRECT ANSWER: A. Serum potassium 6.4 mEq/L
Rationale: Hyperkalemia above 6.0 mEq/L in chronic kidney disease can cause fatal
cardiac dysrhythmias and requires immediate intervention. Creatinine of 3.2 mg/dL and
blood urea nitrogen of 45 mg/dL are expected in chronic kidney disease. Hemoglobin of
10.2 g/dL reflects anemia of chronic kidney disease, which is managed chronically.
Potassium of 6.4 mEq/L may require calcium gluconate, insulin, and glucose.
Question 8: A nurse is teaching a patient about a low-sodium diet for hypertension.
Which food selection indicates correct understanding?
A. Fresh grilled chicken with herbs
B. Canned tomato soup
C. Deli turkey sandwich
D. Frozen lasagna dinner
CORRECT ANSWER: A. Fresh grilled chicken with herbs
Rationale: Fresh grilled chicken seasoned with herbs is naturally low in sodium. Canned
tomato soup, deli turkey, and frozen lasagna dinners are all processed foods high in
sodium. Processed and prepared foods are the primary sources of dietary sodium.
Reading nutrition labels helps patients identify hidden sodium. A low-sodium diet helps
control blood pressure and reduce fluid retention.
Question 9: A nurse is caring for a patient receiving a blood transfusion. Ten
minutes into the transfusion, the patient develops fever, chills, and flank pain.
What is the nurse's priority action?
A. Slow the transfusion rate
B. Stop the transfusion immediately
, C. Administer acetaminophen
D. Obtain a urine specimen
CORRECT ANSWER: B. Stop the transfusion immediately
Rationale: Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction,
which can be fatal. The transfusion must be stopped immediately to prevent further
hemolysis. Slowing the rate does not halt the reaction. Acetaminophen treats fever but
does not address the underlying hemolysis. Urine specimens are collected after
stopping the transfusion. The blood bank and provider must be notified promptly.
Question 10: A nurse is assessing a patient with a suspected pulmonary embolism.
Which finding is most common?
A. Sudden onset of dyspnea
B. Bradycardia
C. Hypertension
D. Productive cough
CORRECT ANSWER: A. Sudden onset of dyspnea
Rationale: Sudden onset of dyspnea is the most common presenting symptom of
pulmonary embolism. Tachycardia, not bradycardia, is typical due to compensatory
mechanisms. Hypotension may occur in massive pulmonary embolism, but
hypertension is not typical. Cough, when present, is usually nonproductive. Prompt
recognition allows initiation of anticoagulation and supportive care.
Question 11: A nurse is teaching a patient about metformin. Which instruction is
most important to include?
A. "Take the medication with meals."
B. "Take the medication on an empty stomach."
C. "Stop the medication if you have a cold."
D. "Double the dose if you miss one."
CORRECT ANSWER: A. "Take the medication with meals."
Rationale: Taking metformin with meals reduces gastrointestinal side e ects such as
nausea and diarrhea. Taking it on an empty stomach increases GI intolerance.
Metformin is not stopped for a cold, though it is held before contrast procedures.
Doubling doses is dangerous and can cause lactic acidosis. Taking with meals improves
adherence and tolerability.
Question 12: A nurse is assessing a patient with left-sided heart failure. Which
finding is most expected?
furosemide for three days. Which assessment finding requires immediate
intervention?
A. Blood pressure 112/68 mm Hg
B. Serum potassium 2.8 mEq/L
C. Urine output 60 mL/hr
D. Weight loss of 1 kg
CORRECT ANSWER: B. Serum potassium 2.8 mEq/L
Rationale: Furosemide is a loop diuretic that causes significant potassium loss, and a
level of 2.8 mEq/L is critically low. Hypokalemia predisposes the patient to ventricular
dysrhythmias, muscle weakness, and ileus. Blood pressure of 112/68 mm Hg is
acceptable. Urine output of 60 mL/hr indicates adequate diuresis. A 1 kg weight loss
reflects appropriate fluid removal. Immediate potassium replacement and cardiac
monitoring are required.
Question 2: A nurse is preparing to administer digoxin to a patient with heart failure.
Which assessment finding should cause the nurse to withhold the medication?
A. Heart rate 52 beats/min
B. Blood pressure 128/76 mm Hg
C. Serum potassium 4.2 mEq/L
D. Digoxin level 1.2 ng/mL
CORRECT ANSWER: A. Heart rate 52 beats/min
Rationale: Digoxin slows cardiac conduction, and a heart rate below 60 beats/min in
adults warrants holding the dose. Blood pressure of 128/76 mm Hg is within normal
limits. Serum potassium of 4.2 mEq/L is normal and does not require holding. A digoxin
level of 1.2 ng/mL is therapeutic. Administering digoxin at this heart rate could cause
severe bradycardia or heart block.
Question 3: A patient is receiving heparin sodium via continuous intravenous
infusion. Which laboratory value should the nurse monitor to evaluate therapeutic
e ectiveness?
A. Prothrombin time
B. International normalized ratio
C. Activated partial thromboplastin time
D. Bleeding time
CORRECT ANSWER: C. Activated partial thromboplastin time
Rationale: Activated partial thromboplastin time measures the intrinsic coagulation
pathway and is the standard test for monitoring unfractionated heparin. Prothrombin
,time and international normalized ratio monitor warfarin therapy. Bleeding time
assesses platelet function, not heparin e ect. The therapeutic goal for heparin is an
aPTT of 1.5 to 2.5 times the control value. Monitoring prevents both bleeding and
thrombotic complications.
Question 4: A nurse is teaching a patient who is starting warfarin therapy. Which
statement by the patient indicates a need for further teaching?
A. "I will use an electric razor instead of a disposable one."
B. "I will increase my intake of spinach and kale."
C. "I will keep all follow-up appointments for blood tests."
D. "I will report any unusual bruising or bleeding."
CORRECT ANSWER: B. "I will increase my intake of spinach and kale."
Rationale: Spinach and kale are rich in vitamin K, which antagonizes warfarin and
reduces its anticoagulant e ect. Patients should maintain a consistent, not increased,
intake of vitamin K-rich foods. Using an electric razor reduces bleeding risk from nicks.
Keeping follow-up appointments for INR monitoring is essential. Reporting unusual
bruising or bleeding is appropriate. This statement indicates a misunderstanding
requiring correction.
Question 5: A nurse is caring for a patient with a new diagnosis of type 1 diabetes
mellitus. Which statement by the patient indicates correct understanding of insulin
administration?
A. "I will rotate injection sites within the same area."
B. "I will inject into the same spot each time."
C. "I will massage the site vigorously after injection."
D. "I will store my insulin in the freezer."
CORRECT ANSWER: A. "I will rotate injection sites within the same area."
Rationale: Rotating injection sites within the same anatomic area maintains consistent
absorption while preventing lipohypertrophy. Injecting into the same spot causes scar
tissue and erratic absorption. Vigorous massage increases absorption rate
unpredictably and causes bruising. Insulin must never be frozen because freezing
destroys its potency. Proper site rotation ensures reliable glycemic control.
Question 6: A nurse is assessing a patient with diabetic ketoacidosis. Which finding
is most consistent with this diagnosis?
A. Blood glucose 620 mg/dL with pH 7.25
B. Blood glucose 210 mg/dL with pH 7.48
C. Blood glucose 95 mg/dL with pH 7.38
D. Blood glucose 480 mg/dL with pH 7.42
,CORRECT ANSWER: A. Blood glucose 620 mg/dL with pH 7.25
Rationale: Diabetic ketoacidosis presents with marked hyperglycemia, metabolic
acidosis, and ketonemia. A glucose of 620 mg/dL with a pH of 7.25 reflects the
hyperglycemia and acidosis characteristic of DKA. Glucose of 210 mg/dL with pH 7.48
suggests alkalosis, not DKA. Glucose of 95 mg/dL is normal and inconsistent with DKA.
Glucose of 480 mg/dL with pH 7.42 lacks the acidosis required for DKA diagnosis.
Question 7: A nurse is reviewing laboratory values for a patient with chronic kidney
disease. Which finding requires immediate follow-up?
A. Serum potassium 6.4 mEq/L
B. Serum creatinine 3.2 mg/dL
C. Blood urea nitrogen 45 mg/dL
D. Hemoglobin 10.2 g/dL
CORRECT ANSWER: A. Serum potassium 6.4 mEq/L
Rationale: Hyperkalemia above 6.0 mEq/L in chronic kidney disease can cause fatal
cardiac dysrhythmias and requires immediate intervention. Creatinine of 3.2 mg/dL and
blood urea nitrogen of 45 mg/dL are expected in chronic kidney disease. Hemoglobin of
10.2 g/dL reflects anemia of chronic kidney disease, which is managed chronically.
Potassium of 6.4 mEq/L may require calcium gluconate, insulin, and glucose.
Question 8: A nurse is teaching a patient about a low-sodium diet for hypertension.
Which food selection indicates correct understanding?
A. Fresh grilled chicken with herbs
B. Canned tomato soup
C. Deli turkey sandwich
D. Frozen lasagna dinner
CORRECT ANSWER: A. Fresh grilled chicken with herbs
Rationale: Fresh grilled chicken seasoned with herbs is naturally low in sodium. Canned
tomato soup, deli turkey, and frozen lasagna dinners are all processed foods high in
sodium. Processed and prepared foods are the primary sources of dietary sodium.
Reading nutrition labels helps patients identify hidden sodium. A low-sodium diet helps
control blood pressure and reduce fluid retention.
Question 9: A nurse is caring for a patient receiving a blood transfusion. Ten
minutes into the transfusion, the patient develops fever, chills, and flank pain.
What is the nurse's priority action?
A. Slow the transfusion rate
B. Stop the transfusion immediately
, C. Administer acetaminophen
D. Obtain a urine specimen
CORRECT ANSWER: B. Stop the transfusion immediately
Rationale: Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction,
which can be fatal. The transfusion must be stopped immediately to prevent further
hemolysis. Slowing the rate does not halt the reaction. Acetaminophen treats fever but
does not address the underlying hemolysis. Urine specimens are collected after
stopping the transfusion. The blood bank and provider must be notified promptly.
Question 10: A nurse is assessing a patient with a suspected pulmonary embolism.
Which finding is most common?
A. Sudden onset of dyspnea
B. Bradycardia
C. Hypertension
D. Productive cough
CORRECT ANSWER: A. Sudden onset of dyspnea
Rationale: Sudden onset of dyspnea is the most common presenting symptom of
pulmonary embolism. Tachycardia, not bradycardia, is typical due to compensatory
mechanisms. Hypotension may occur in massive pulmonary embolism, but
hypertension is not typical. Cough, when present, is usually nonproductive. Prompt
recognition allows initiation of anticoagulation and supportive care.
Question 11: A nurse is teaching a patient about metformin. Which instruction is
most important to include?
A. "Take the medication with meals."
B. "Take the medication on an empty stomach."
C. "Stop the medication if you have a cold."
D. "Double the dose if you miss one."
CORRECT ANSWER: A. "Take the medication with meals."
Rationale: Taking metformin with meals reduces gastrointestinal side e ects such as
nausea and diarrhea. Taking it on an empty stomach increases GI intolerance.
Metformin is not stopped for a cold, though it is held before contrast procedures.
Doubling doses is dangerous and can cause lactic acidosis. Taking with meals improves
adherence and tolerability.
Question 12: A nurse is assessing a patient with left-sided heart failure. Which
finding is most expected?
