1. The nurse is caring for a patient with acute kidney injury. Which
electrolyte imbalance is most critical to address?
A. Sodium: 125 mEq/L
B. Potassium: 6.8 mEq/L
C. Calcium: 8.0 mg/dL
D. Phosphorus: 5.5 mg/dL
Answer and Rationale:
B. Potassium: 6.8 mEq/L
Rationale: Hyperkalemia can cause life-threatening cardiac arrhythmias
and requires immediate intervention.
2. A patient with deep vein thrombosis is prescribed enoxaparin. What
is the nurse’s priority assessment?
A. Platelet count
B. INR levels
C. Pain scale
D. Lung sounds
Answer and Rationale:
A. Platelet count
Rationale: Monitoring for thrombocytopenia is crucial to detect HIT, a
potential complication of enoxaparin therapy.
,3. A patient on warfarin therapy has an INR of 4.5. What is the nurse’s
priority intervention?
A. Notify the healthcare provider.
B. Administer vitamin K as prescribed.
C. Hold the next dose of warfarin.
D. Assess the patient for signs of bleeding.
Answer and Rationale:
D. Assess the patient for signs of bleeding.
Rationale: An elevated INR increases the risk of bleeding, and
assessment ensures early detection of complications.
4. A patient with a history of heart failure presents with sudden weight
gain of 5 lbs in 2 days, peripheral edema, and jugular vein distention.
What is the nurse’s priority intervention?
A. Administer prescribed diuretics.
B. Restrict oral fluid intake.
C. Monitor intake and output.
D. Elevate the legs to reduce edema.
Answer and Rationale:
A. Administer prescribed diuretics.
Rationale: Diuretics help remove excess fluid and alleviate symptoms of
fluid overload.
, 5. A patient with COPD reports increased shortness of breath. Which
action should the nurse take first?
A. Administer a prescribed bronchodilator.
B. Obtain an arterial blood gas (ABG) sample.
C. Increase oxygen flow.
D. Assess lung sounds and respiratory effort.
Answer and Rationale:
D. Assess lung sounds and respiratory effort.
Rationale: Assessment identifies the cause of the shortness of breath
and guides further interventions.
6. A patient with pneumonia is on oxygen therapy but remains hypoxic
with an SpO2 of 88%. What is the next appropriate intervention?
A. Increase oxygen flow rate.
B. Notify the healthcare provider.
C. Prepare for intubation.
D. Assess for signs of respiratory fatigue.
Answer and Rationale:
A. Increase oxygen flow rate.
Rationale: Increasing the oxygen flow rate is the immediate action to
improve oxygenation while further assessing the patient.
electrolyte imbalance is most critical to address?
A. Sodium: 125 mEq/L
B. Potassium: 6.8 mEq/L
C. Calcium: 8.0 mg/dL
D. Phosphorus: 5.5 mg/dL
Answer and Rationale:
B. Potassium: 6.8 mEq/L
Rationale: Hyperkalemia can cause life-threatening cardiac arrhythmias
and requires immediate intervention.
2. A patient with deep vein thrombosis is prescribed enoxaparin. What
is the nurse’s priority assessment?
A. Platelet count
B. INR levels
C. Pain scale
D. Lung sounds
Answer and Rationale:
A. Platelet count
Rationale: Monitoring for thrombocytopenia is crucial to detect HIT, a
potential complication of enoxaparin therapy.
,3. A patient on warfarin therapy has an INR of 4.5. What is the nurse’s
priority intervention?
A. Notify the healthcare provider.
B. Administer vitamin K as prescribed.
C. Hold the next dose of warfarin.
D. Assess the patient for signs of bleeding.
Answer and Rationale:
D. Assess the patient for signs of bleeding.
Rationale: An elevated INR increases the risk of bleeding, and
assessment ensures early detection of complications.
4. A patient with a history of heart failure presents with sudden weight
gain of 5 lbs in 2 days, peripheral edema, and jugular vein distention.
What is the nurse’s priority intervention?
A. Administer prescribed diuretics.
B. Restrict oral fluid intake.
C. Monitor intake and output.
D. Elevate the legs to reduce edema.
Answer and Rationale:
A. Administer prescribed diuretics.
Rationale: Diuretics help remove excess fluid and alleviate symptoms of
fluid overload.
, 5. A patient with COPD reports increased shortness of breath. Which
action should the nurse take first?
A. Administer a prescribed bronchodilator.
B. Obtain an arterial blood gas (ABG) sample.
C. Increase oxygen flow.
D. Assess lung sounds and respiratory effort.
Answer and Rationale:
D. Assess lung sounds and respiratory effort.
Rationale: Assessment identifies the cause of the shortness of breath
and guides further interventions.
6. A patient with pneumonia is on oxygen therapy but remains hypoxic
with an SpO2 of 88%. What is the next appropriate intervention?
A. Increase oxygen flow rate.
B. Notify the healthcare provider.
C. Prepare for intubation.
D. Assess for signs of respiratory fatigue.
Answer and Rationale:
A. Increase oxygen flow rate.
Rationale: Increasing the oxygen flow rate is the immediate action to
improve oxygenation while further assessing the patient.
