Paging Dr. Doom
The nurse is administering Alteplase to a stroke patient. What action ensures safe drug administration?
A) Administer the full dose over 30 minutes
B) Use a programmable infusion pump and never manually push the drug
C) Administer a saline bolus before infusion
D) Give 50% as a bolus, then the rest over an hour
Use a programmable infusion pump and never manually push the drug
A nurse is monitoring a patient in a cast for compartment syndrome. Which finding requires immediate action?
A. Capillary refill <2 seconds
B. Reports tingling in fingers
C. Absent pulse distal to the cast
D. Mild swelling and warmth
C. Absent pulse distal to the cast
What is the most appropriate reason for removing a central line?
A. The patient has received 3 days of antibiotics
B. The line was placed in the emergency department
C. The line is no longer clinically indicated
D. The dressing was soiled with blood
The line is no longer clinically indicated
The nurse reviews the lab results of a patient post-CABG and notes potassium of 3.0 mEq/L and a new irregular heart rhythm on telemetry. What is the most appropriate nursing action?
A) Prepare for synchronized cardioversion
B) Anticipate potassium replacement
C) Ask the patient to bear down and perform vagal maneuvers
D) Continue monitoring; potassium level is expected post-op
B) Anticipate potassium replacement
1. A 78-year-old patient presents after a ground-level fall with sudden back pain and loss of height. What is the nurse’s priority assessment?
A. Check for a pelvic hematoma
B. Assess for kyphosis and neuro changes
C. Perform a pain assessment using the FLACC scale
D. Apply a heating pad to the lumbar spine
B. Assess for kyphosis and neuro changes
The nurse is teaching about open and closed TBIs. Which statement by a student indicates a need for further teaching?
A. “A depressed skull fracture is considered an open brain injury.”
B. “Closed TBIs can still cause serious complications like increased ICP.”
C. “Open TBIs are less likely to get infected since the skull is fractured.”
D. “Closed TBIs may not be obvious on initial assessment.”
C. “Open TBIs are less likely to get infected since the skull is fractured.”
A nurse is caring for a patient with suspected septic shock. Which physician order should the nurse implement first?
A. Draw a complete blood count (CBC)
B. Administer IV ceftriaxone
C. Infuse 0.9% NS at 30 mL/kg
D. Place Foley catheter
Infuse 0.9% NS at 30 mL/kg
A patient with a new long bone fracture begins reporting severe pain with passive motion. The extremity is tense and pale. What should the nurse do first?
A. Elevate the extremity above the heart
B. Loosen tight dressings and notify the provider
C. Administer morphine for pain relief
D. Apply ice packs to reduce swelling
B. Loosen tight dressings and notify the provider
1. A nurse is caring for a patient who is 24 hours post-liver transplant. Which finding requires immediate intervention?
A. Serum bilirubin 0.9 mg/dL
B. Yellow-green bile in JP drain
C. Fever and right upper quadrant pain
D. Mild elevation in ALT and AST
C. Fever and right upper quadrant pain
During repositioning, the patient’s chest tube becomes dislodged from the insertion site. What is the nurse’s first action?
A. Notify the provider
B. Apply a sterile occlusive dressing and tape on 3 sides
C. Flush the tube with sterile saline
D. Reinsert the tube using sterile technique
Apply a sterile occlusive dressing and tape on 3 sides
A patient with a femur fracture 36 hours ago is now restless, tachycardic, and has non-palpable petechiae on the chest. What should the nurse anticipate?
A. Administer a fluid bolus
B. Prepare for intubation and notify provider
C. Use the incentive spiromoeter
D. Reassure the patient and monitor vital signs
B. Prepare for intubation and notify provider
A patient with newly diagnosed Type I diabetes presents with DKA. Which provider order should the nurse question?
A. Start 0.9% NS bolus
B. Administer insulin glargine subcutaneously
C. Begin regular insulin drip
D. Administer potassium chloride if K+ < 3.3 mEq/L
B. Administer insulin glargine subcutaneously
A patient with a right subclavian central line suddenly complains of chest pain and shortness of breath. What should the nurse do first?
A. Call the provider to report possible infection
B. Clamp the central line and reposition the patient
C. Administer oxygen and obtain vital signs
D. Flush the catheter with normal saline
Administer oxygen and obtain vital signs
A student nurse asks why lactate is drawn in a septic patient. What is the best explanation the nurse can provide?
A. "It checks for infection in the blood."
B. "It tells us if the patient is dehydrated."
C. "It reflects how well the body is being perfused."
D. "It shows how much bacteria is present."
"It reflects how well the body is being perfused."
State the area on the documentation that requires follow-up.
Nursing Note:
“Chest tube to suction. Water seal chamber has gentle bubbling. Output is 30 mL clear fluid. Dressing dry and intact. Drainage system was clamped to reposition the patient. Patient reports mild discomfort at site.”
Drainage system was clamped to reposition the patient
Question 2: Multiple Response – Which of the following ECG findings are consistent with atrial fibrillation?
Select all that apply:
• Irregular rhythm
• Absence of distinct P waves
• Sawtooth flutter waves
• Normal PR interval
• Variable ventricular rate
Irregularly irregular rhythm
Absence of distinct P waves
Variable ventricular rate
Which condition is most likely to lead to obstructive shock?
A. Gastrointestinal bleeding
B. Anterior wall MI
C. Pulmonary embolism
D. Systemic allergic reaction
C. Pulmonary embolism
A patient being treated for small bowel obstruction reports worsening pain and no relief with prescribed analgesia. Which action should the nurse take first?
A) Administer an additional dose of pain medication
B) Perform a focused abdominal assessment
C) Reposition the patient with knees flexed
D) Notify dietary to hold oral intake
B) Perform a focused abdominal assessment
Which of the following should the nurse include when teaching a family how increased ICP is managed? (Select all that apply)
A. The patient may be sedated to reduce metabolic demand
B. Elevating the head of the bed helps reduce ICP
C. Deep suctioning every hour is necessary
D. Hypertonic saline may be used
E. Cluster care activities to promote rest
A. The patient may be sedated to reduce metabolic demand
B. Elevating the head of the bed helps reduce ICP
D. Hypertonic saline may be used
5. A patient with alcohol use disorder is admitted. Which assessment finding indicates the patient may be developing delirium tremens?
A. BP 130/82, sleepy but arousable
B. Mild tremors and reports of nausea
C. Confusion, hallucinations, and tremors
D. Diaphoresis and verbalizing desire to quit drinking
C. Confusion, hallucinations, and tremors
A 76-year-old with osteoporosis reports new-onset thoracic spine pain and difficulty walking. What nursing intervention is most appropriate?
A. Begin hourly range-of-motion exercises
B. Place in prone position to reduce pressure
C. Encourage ambulation to improve bone strength
D. Log roll the patient and notify the provider
Log roll the patient and notify the provider
A nurse is preparing to initiate an insulin drip for a patient admitted with diabetic ketoacidosis (DKA). The following labs are reported:
Potassium (K⁺): 2.8 mEq/L (Normal: 3.5–5.0 mEq/L)
Glucose: 625 mg/dL (Normal: 70–110 mg/dL)
Sodium: 132 mEq/L (Normal: 135–145 mEq/L)
Bicarbonate (HCO₃⁻): 12 mEq/L (Normal: 22–26 mEq/L)
pH: 7.12 (Normal: 7.35–7.45)
The patient has two large-bore IVs and telemetry monitoring.
In what order would you implement the interventions?
A. Start the insulin drip at 0.1 units/kg/hr per protocol to reduce serum glucose
B. Administer potassium chloride replacement
C. Begin IV fluid resuscitation with 0.9% normal saline
D. Prepare to add dextrose to IV fluids once blood glucose approaches 250 mg/dL
B. Administer potassium chloride replacement
C. Begin IV fluid resuscitation with 0.9% normal saline
Start the insulin drip at 0.1 units/kg/hr per protocol to reduce serum glucose
D. Prepare to add dextrose to IV fluids once blood glucose approaches 250 mg/dL
A nurse is caring for a patient with a suspected closed TBI following a motor vehicle collision. Which assessment finding requires immediate action?
A. Complaints of headache and dizziness
B. Bilateral periorbital ecchymosis
C. Sudden decrease in level of consciousness
D. Clear fluid draining from the nose
Sudden decrease in level of consciousness
A patient arrives after a diving accident. They are alert but unable to move their arms or legs. What is the nurse’s priority action?
A. Immediate intubation
B. Apply an external pacemaker to prepare for neurogenic shock
C. Maintain cervical spine immobilization
D. Insert a Foley catheter to prevent dysautonomia reactions
Maintain cervical spine immobilization
Which of the following assessment findings may indicate increased intracranial pressure? (Select all that apply)
A. Restlessness
B. Unilateral pupil dilation
C. Bradycardia
D. Hypertension with widening pulse pressure
E. Tachypnea
A. Restlessness
B. Unilateral pupil dilation
C. Bradycardia
D. Hypertension with widening pulse pressure