1. A patient with a pulmonary embolism is started on a heparin
infusion. Which lab value should the nurse monitor closely?
A. PT/INR
B. aPTT
C. Platelet count
D. D-dimer
Answer and Rationale:
B. aPTT
Rationale: Heparin therapy is monitored using aPTT levels to ensure
therapeutic anticoagulation.
2. A patient is admitted with a potassium level of 6.5 mEq/L. Which
intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate).
B. Start an IV infusion of regular insulin and dextrose.
C. Monitor for peaked T waves on the ECG.
D. Administer calcium gluconate IV as prescribed.
Answer and Rationale:
D. Administer calcium gluconate IV as prescribed.
,Rationale: Calcium gluconate stabilizes the cardiac membrane and
prevents arrhythmias, which is the priority in hyperkalemia
management.
3. A patient with a history of stroke is found to have unilateral facial
drooping and slurred speech. What is the nurse’s priority?
A. Perform a neurological assessment.
B. Notify the healthcare provider immediately.
C. Check blood glucose levels.
D. Obtain a CT scan of the head.
Answer and Rationale:
B. Notify the healthcare provider immediately.
Rationale: Time-sensitive intervention is crucial for stroke
management, and notifying the provider ensures timely diagnostic and
therapeutic measures.
4. A patient is admitted with a suspected pulmonary embolism. Which
diagnostic test does the nurse anticipate?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. Arterial blood gas (ABG)
Answer and Rationale:
, C. CT pulmonary angiography
Rationale: This is the gold standard for diagnosing pulmonary
embolism.
5. A patient with sepsis is receiving norepinephrine via continuous
infusion. Which parameter is the priority to monitor?
A. Heart rate
B. Urine output
C. Mean arterial pressure (MAP)
D. Central venous pressure (CVP)
Answer and Rationale:
C. Mean arterial pressure (MAP)
Rationale: The primary goal of norepinephrine in sepsis is to maintain
adequate MAP for organ perfusion.
6. A patient on warfarin reports black tarry stools. What is the nurse’s
first action?
A. Notify the healthcare provider immediately.
B. Hold the next dose of warfarin.
C. Check the INR level.
D. Assess for signs of bleeding.
Answer and Rationale:
D. Assess for signs of bleeding.
infusion. Which lab value should the nurse monitor closely?
A. PT/INR
B. aPTT
C. Platelet count
D. D-dimer
Answer and Rationale:
B. aPTT
Rationale: Heparin therapy is monitored using aPTT levels to ensure
therapeutic anticoagulation.
2. A patient is admitted with a potassium level of 6.5 mEq/L. Which
intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate).
B. Start an IV infusion of regular insulin and dextrose.
C. Monitor for peaked T waves on the ECG.
D. Administer calcium gluconate IV as prescribed.
Answer and Rationale:
D. Administer calcium gluconate IV as prescribed.
,Rationale: Calcium gluconate stabilizes the cardiac membrane and
prevents arrhythmias, which is the priority in hyperkalemia
management.
3. A patient with a history of stroke is found to have unilateral facial
drooping and slurred speech. What is the nurse’s priority?
A. Perform a neurological assessment.
B. Notify the healthcare provider immediately.
C. Check blood glucose levels.
D. Obtain a CT scan of the head.
Answer and Rationale:
B. Notify the healthcare provider immediately.
Rationale: Time-sensitive intervention is crucial for stroke
management, and notifying the provider ensures timely diagnostic and
therapeutic measures.
4. A patient is admitted with a suspected pulmonary embolism. Which
diagnostic test does the nurse anticipate?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. Arterial blood gas (ABG)
Answer and Rationale:
, C. CT pulmonary angiography
Rationale: This is the gold standard for diagnosing pulmonary
embolism.
5. A patient with sepsis is receiving norepinephrine via continuous
infusion. Which parameter is the priority to monitor?
A. Heart rate
B. Urine output
C. Mean arterial pressure (MAP)
D. Central venous pressure (CVP)
Answer and Rationale:
C. Mean arterial pressure (MAP)
Rationale: The primary goal of norepinephrine in sepsis is to maintain
adequate MAP for organ perfusion.
6. A patient on warfarin reports black tarry stools. What is the nurse’s
first action?
A. Notify the healthcare provider immediately.
B. Hold the next dose of warfarin.
C. Check the INR level.
D. Assess for signs of bleeding.
Answer and Rationale:
D. Assess for signs of bleeding.
