Sample Questions and Answers
A patient who has undergone major surgery begins to exhibit signs of confusion, agitation, and elevated heart rate. The nurse should first assess for which of the following complications?
A) Sepsis
B) Hypoxia
C) Electrolyte imbalance
D) Acute delirium
Answer: B) Hypoxia
Explanation: Confusion and agitation after surgery may be indicative of hypoxia, which can result from insufficient oxygen delivery to tissues. The nurse should check oxygen saturation and assess for signs of respiratory distress.
A nurse is caring for a patient who is receiving continuous intravenous heparin therapy. Which of the following laboratory values is essential to monitor?
A) Platelet count
B) Prothrombin time (PT)
C) Activated partial thromboplastin time (aPTT)
D) International normalized ratio (INR)
Answer: C) Activated partial thromboplastin time (aPTT)
Explanation: Heparin therapy requires frequent monitoring of aPTT levels to ensure the patient is receiving the appropriate level of anticoagulation therapy.
A critically ill patient develops a fever after surgery. The nurse should first assess for which of the following complications?
A) Infection
B) Hypotension
C) Myocardial infarction
D) Electrolyte imbalance
Answer: A) Infection
Explanation: A fever following surgery may be a sign of infection, particularly if there are other signs such as wound redness, swelling, or drainage.
A nurse is caring for a patient in the ICU who has received several units of blood transfusion. The nurse should monitor for which of the following potential complications?
A) Anemia
B) Hyperkalemia
C) Hyperthermia
D) Transfusion reaction
Answer: D) Transfusion reaction
Explanation: Transfusion reactions, such as fever, chills, and allergic responses, can occur during or shortly after a blood transfusion. The nurse should monitor the patient for signs of these reactions.
A patient with a history of hypertension is admitted with a hypertensive crisis. The nurse anticipates the administration of which of the following medications?
A) Lisinopril
B) Furosemide
C) Nitroprusside
D) Prednisone
Answer: C) Nitroprusside
Explanation: Nitroprusside is a potent vasodilator used in hypertensive crises to quickly lower blood pressure and prevent damage to target organs.
A nurse is caring for a patient with acute kidney injury (AKI). Which of the following is an expected finding in the patient’s laboratory results?
A) Hypercalcemia
B) Hypernatremia
C) Elevated creatinine levels
D) Hypoglycemia
Answer: C) Elevated creatinine levels
Explanation: Elevated serum creatinine is a key indicator of impaired renal function and is commonly seen in patients with acute kidney injury.
A patient with a history of chronic liver disease presents with confusion, lethargy, and asterixis. The nurse should suspect which of the following conditions?
A) Hepatic encephalopathy
B) Cirrhosis
C) Acute pancreatitis
D) Gallbladder disease
Answer: A) Hepatic encephalopathy
Explanation: Hepatic encephalopathy is a complication of liver failure characterized by neurological symptoms such as confusion, lethargy, and asterixis (flapping tremor of the hands).
A nurse is caring for a patient with diabetic ketoacidosis (DKA). Which of the following interventions should be prioritized during the initial treatment?
A) Administering insulin
B) Administering potassium
C) Administering sodium bicarbonate
D) Administering morphine
Answer: A) Administering insulin
Explanation: The first priority in managing DKA is administering insulin to lower blood glucose levels and stop the production of ketones, which are causing the metabolic acidosis.
A patient in the ICU is receiving mechanical ventilation with high levels of positive end-expiratory pressure (PEEP). The nurse should monitor for which of the following complications?
A) Barotrauma
B) Hypoxia
C) Hypercapnia
D) Pneumonia
Answer: A) Barotrauma
Explanation: High levels of PEEP can cause barotrauma, which is damage to the lungs due to high airway pressures. The nurse should monitor for signs of pneumothorax or other lung injury.
A critically ill patient is receiving fluid resuscitation for shock. The nurse should monitor which of the following indicators to assess the effectiveness of fluid replacement?
A) Urinary output
B) Hemoglobin levels
C) Blood glucose levels
D) Platelet count
Answer: A) Urinary output
Explanation: Urinary output is a reliable indicator of kidney perfusion and the effectiveness of fluid resuscitation in patients with shock.
A nurse is caring for a patient who is receiving enteral nutrition. The nurse should monitor for which of the following potential complications?
A) Diarrhea
B) Hypokalemia
C) Hyperglycemia
D) Hypercalcemia
Answer: A) Diarrhea
Explanation: Enteral nutrition can lead to diarrhea due to the osmotic load or intolerance to the enteral feeding formula. The nurse should monitor for changes in bowel patterns.
A patient in the ICU is being treated for acute respiratory distress syndrome (ARDS). Which of the following strategies is most likely to improve oxygenation?
A) Use of a high FiO2
B) Prone positioning
C) Administering high doses of corticosteroids
D) Reducing positive end-expiratory pressure (PEEP)
Answer: B) Prone positioning
Explanation: Prone positioning has been shown to improve oxygenation in patients with ARDS by promoting better ventilation-perfusion matching in the lungs.
A critically ill patient with a severe burn injury develops an infection. The nurse should anticipate the administration of which of the following treatments?
A) Topical antifungal agents
B) Oral antibiotics
C) Intravenous antibiotics
D) Corticosteroids
Answer: C) Intravenous antibiotics
Explanation: Severe burn injuries significantly increase the risk of infection, and intravenous antibiotics are typically used to manage systemic infections.
A nurse is caring for a patient with a history of coronary artery disease (CAD) who develops chest pain. Which of the following medications is the nurse likely to administer first?
A) Nitroglycerin
B) Aspirin
C) Heparin
D) Metoprolol
Answer: A) Nitroglycerin
Explanation: Nitroglycerin is administered to relieve chest pain by dilating coronary arteries and improving blood flow to the heart muscle in patients with CAD.
A patient in the ICU develops a deep vein thrombosis (DVT) following major surgery. Which of the following is the most appropriate nursing action?
A) Administer aspirin
B) Begin anticoagulation therapy
C) Apply cold compresses
D) Elevate the affected leg
Answer: B) Begin anticoagulation therapy
Explanation: Anticoagulation therapy, such as heparin, is the primary treatment for DVT to prevent the clot from enlarging or causing a pulmonary embolism.
A nurse is caring for a patient with an arterial line in place. The nurse should monitor for which of the following potential complications?
A) Infection
B) Hemorrhage
C) Hyperkalemia
D) Hypoglycemia
Answer: B) Hemorrhage
Explanation: One of the main complications of an arterial line is hemorrhage, which can occur if the line becomes dislodged or the pressure is not properly managed.
A critically ill patient is diagnosed with disseminated intravascular coagulation (DIC). The nurse should monitor for which of the following signs?
A) Increased platelet count
B) Oozing from wounds and IV sites
C) Increased hematocrit
D) Decreased prothrombin time (PT)
Answer: B) Oozing from wounds and IV sites
Explanation: DIC is characterized by widespread clotting and bleeding. The nurse should monitor for signs of bleeding, such as oozing from wounds and IV sites.
A patient with a history of chronic kidney disease (CKD) is being treated for hyperkalemia. The nurse should prioritize which of the following interventions?
A) Administering sodium bicarbonate
B) Restricting fluid intake
C) Administering potassium-sparing diuretics
D) Monitoring ECG for signs of arrhythmias
Answer: D) Monitoring ECG for signs of arrhythmias
Explanation: Hyperkalemia can cause life-threatening arrhythmias, so it’s important to closely monitor the ECG to identify any changes, especially the classic peaked T-waves.
A critically ill patient with acute respiratory failure is receiving non-invasive positive pressure ventilation (NIPPV). The nurse should assess for which of the following complications?
A) Gastroesophageal reflux disease (GERD)
B) Skin breakdown from the mask
C) Increased work of breathing
D) Decreased oxygen saturation
Answer: B) Skin breakdown from the mask
Explanation: Prolonged use of NIPPV can cause pressure ulcers or skin breakdown where the mask contacts the face, requiring regular assessment of skin integrity.
A patient with sepsis is being treated with broad-spectrum antibiotics. Which of the following is the most important nursing intervention to prevent antibiotic resistance?
A) Administering antibiotics as prescribed
B) Encouraging fluid intake
C) Discontinuing antibiotics as soon as the patient shows improvement
D) Culturing the patient’s blood before starting antibiotics
Answer: D) Culturing the patient’s blood before starting antibiotics
Explanation: Culturing before starting antibiotics allows the identification of the pathogen and helps guide targeted therapy, minimizing the risk of resistance.
A nurse is caring for a patient who is post-surgical and receiving epidural analgesia. The nurse should assess for which of the following complications?
A) Hypoventilation
B) Hypertension
C) Bradycardia
D) Increased urinary output
Answer: A) Hypoventilation
Explanation: Epidural analgesia, especially with opioids, can cause respiratory depression and hypoventilation, requiring continuous monitoring of respiratory status.
A patient with a history of stroke is being monitored in the ICU. Which of the following is the most appropriate nursing intervention for preventing complications associated with immobility?
A) Encouraging fluid intake
B) Performing passive range-of-motion exercises
C) Administering antiplatelet therapy
D) Elevating the head of the bed
Answer: B) Performing passive range-of-motion exercises
Explanation: Immobilized patients are at risk for contractures and deep vein thrombosis (DVT). Passive range-of-motion exercises help maintain joint flexibility and prevent complications.
A patient is being treated for acute pancreatitis. The nurse should monitor for which of the following potential complications?
A) Hypoglycemia
B) Hyperkalemia
C) Acute renal failure
D) Hypertension
Answer: C) Acute renal failure
Explanation: Acute pancreatitis can lead to renal failure due to hypoperfusion and sepsis, making it important to monitor kidney function closely.
A nurse is caring for a patient with a history of atrial fibrillation (AF) and is receiving anticoagulation therapy. Which of the following is a sign of excessive anticoagulation?
A) Increased platelet count
B) Bradycardia
C) Unexplained bruising
D) Hypertension
Answer: C) Unexplained bruising
Explanation: Unexplained bruising is a sign of excessive anticoagulation, which can increase the risk of bleeding. The nurse should monitor the patient’s coagulation profile.
A critically ill patient is receiving intravenous fluids after a severe burn injury. The nurse should monitor for which of the following electrolyte imbalances?
A) Hypokalemia
B) Hyperkalemia
C) Hypercalcemia
D) Hypocalcemia
Answer: B) Hyperkalemia
Explanation: After a burn injury, potassium shifts from the intracellular space to the extracellular space, potentially causing hyperkalemia, which must be closely monitored.
A patient receiving mechanical ventilation develops signs of ventilator-associated pneumonia (VAP). Which of the following interventions is most effective in preventing VAP?
A) Administering corticosteroids
B) Maintaining the head of the bed at 30-45 degrees
C) Administering prophylactic antibiotics
D) Repositioning the endotracheal tube daily
Answer: B) Maintaining the head of the bed at 30-45 degrees
Explanation: Elevating the head of the bed reduces the risk of aspiration and is an evidence-based strategy to prevent ventilator-associated pneumonia.
A nurse is caring for a patient with a chest tube following thoracic surgery. The nurse should assess for which of the following complications?
A) Pneumothorax
B) Hemorrhage
C) Pulmonary embolism
D) Hypovolemia
Answer: B) Hemorrhage
Explanation: Chest tubes are used to drain air, blood, or fluid from the pleural space. Hemorrhage can occur if the chest tube is displaced or if there is a puncture of a blood vessel.
A patient who is critically ill develops acute respiratory distress syndrome (ARDS). The nurse should monitor for which of the following?
A) Cyanosis
B) Decreased heart rate
C) Hyperglycemia
D) Hypotension
Answer: A) Cyanosis
Explanation: ARDS causes severe hypoxemia, leading to cyanosis. Oxygenation support is critical, and the nurse should monitor for any worsening signs of respiratory failure.
A nurse is caring for a patient with diabetic ketoacidosis (DKA). The nurse should prioritize which of the following interventions?
A) Administering insulin
B) Administering sodium bicarbonate
C) Administering potassium
D) Administering morphine
Answer: A) Administering insulin
Explanation: Insulin is the primary treatment for DKA as it helps reduce hyperglycemia and correct metabolic acidosis by halting ketone production.
A patient with liver failure is at risk for bleeding. The nurse should monitor the patient for which of the following findings?
A) Elevated white blood cell count
B) Elevated prothrombin time (PT)
C) Increased platelet count
D) Elevated blood glucose
Answer: B) Elevated prothrombin time (PT)
Explanation: Liver failure impairs the production of clotting factors, leading to an elevated PT and an increased risk for bleeding.
A nurse is caring for a patient post-operatively who is at risk for deep vein thrombosis (DVT). The nurse should implement which of the following interventions?
A) Encouraging bed rest
B) Administering a full dose of vitamin K
C) Applying compression stockings
D) Restricting fluids
Answer: C) Applying compression stockings
Explanation: Compression stockings help prevent the development of deep vein thrombosis by improving venous return and reducing stasis of blood in the lower extremities.
A patient is admitted with suspected carbon monoxide poisoning. Which of the following should the nurse prioritize in the initial assessment?
A) Oxygen saturation levels
B) Carbon monoxide blood levels
C) Vital signs
D) Arterial blood gases (ABG)
Answer: B) Carbon monoxide blood levels
Explanation: The most accurate test to diagnose carbon monoxide poisoning is the measurement of carboxyhemoglobin levels, which will indicate the degree of poisoning.
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should assess the patient for which of the following signs of respiratory failure?
A) Increased respiratory rate
B) Increased urine output
C) Decreased oxygen saturation
D) Increased appetite
Answer: C) Decreased oxygen saturation
Explanation: Decreased oxygen saturation is a critical sign of respiratory failure in patients with COPD and may indicate the need for additional respiratory support.
A nurse is caring for a patient with acute myeloid leukemia (AML). The nurse should monitor for which of the following complications?
A) Hypoglycemia
B) Infection
C) Hypovolemia
D) Hyperkalemia
Answer: B) Infection
Explanation: AML and chemotherapy treatments can suppress the immune system, increasing the risk of infections. The nurse should monitor for fever, chills, and other signs of infection.
A patient with a history of chronic alcoholism is admitted with confusion, agitation, and tremors. The nurse should assess for which of the following withdrawal symptoms?
A) Seizures
B) Hypotension
C) Dehydration
D) Hypertension
Answer: A) Seizures
Explanation: Alcohol withdrawal can cause seizures, particularly in patients with a history of chronic use. The nurse should closely monitor the patient for signs of withdrawal.
A nurse is caring for a patient in shock. Which of the following interventions should the nurse prioritize?
A) Administering fluids to restore intravascular volume
B) Administering antibiotics
C) Administering corticosteroids
D) Encouraging deep breathing exercises
Answer: A) Administering fluids to restore intravascular volume
Explanation: Fluid resuscitation is the priority intervention in treating shock, as it helps restore circulatory volume, improve organ perfusion, and stabilize blood pressure.
A nurse is caring for a patient who has developed a pressure ulcer. Which of the following interventions is most effective in preventing further skin breakdown?
A) Administering pain medications
B) Regularly turning and repositioning the patient
C) Administering antibiotics
D) Applying a wet-to-dry dressing
Answer: B) Regularly turning and repositioning the patient
Explanation: Frequent repositioning is key to preventing further pressure ulcer development by alleviating pressure on vulnerable areas of the body.
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