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A nurse is caring for a patient with heart failure who is prescribed furosemide. Which
finding requires immediate intervention?
A. Urine output of 300 mL in 4 hours
B. Blood pressure of 110/70 mmHg
C. Potassium level of 2.9 mEq/L
D. Mild ankle edema
Answer: C
Rationale: A potassium level of 2.9 mEq/L indicates hypokalemia, a serious
complication of loop diuretics like furosemide. This can lead to life-threatening
arrhythmias and requires immediate correction.
A nurse is caring for a patient with cirrhosis. Which finding requires immediate
attention?
A. Mild jaundice
B. Ascites
C. Confusion and altered mental status
D. Spider angiomas
Answer: C
Rationale: Confusion may indicate hepatic encephalopathy due to ammonia buildup,
which can progress rapidly and requires urgent treatment.
A patient is prescribed digoxin. Which finding suggests toxicity?
,A. Heart rate of 88 bpm
B. Nausea and visual halos
C. Increased appetite
D. Blood pressure of 120/80 mmHg
Answer: B
Rationale: Digoxin toxicity commonly presents with gastrointestinal symptoms and
visual disturbances such as yellow or green halos.
Which intervention is appropriate for a patient with hyperkalemia?
A. Administer potassium supplements
B. Monitor for arrhythmias
C. Encourage high-potassium foods
D. Restrict sodium intake
Answer: B
Rationale: Hyperkalemia can cause life-threatening cardiac arrhythmias, so cardiac
monitoring is essential.
A patient with pancreatitis reports severe abdominal pain. What is the priority
intervention?
A. Provide oral fluids
B. Administer pain medication
C. Encourage ambulation
D. Offer high-fat meals
Answer: B
Rationale: Pain management is critical in pancreatitis to reduce stress and
complications.
Which lab value indicates renal dysfunction?
A. Creatinine 0.8 mg/dL
B. BUN 10 mg/dL
, C. Creatinine 2.5 mg/dL
D. Sodium 140 mEq/L
Answer: C
Rationale: Elevated creatinine indicates impaired kidney function.
A nurse is caring for a patient with hypoglycemia. Which intervention is appropriate?
A. Administer insulin
B. Provide 15 g of fast-acting carbohydrate
C. Restrict fluids
D. Encourage exercise
Answer: B
Rationale: Immediate treatment involves giving a quick source of glucose.
Which symptom indicates hypernatremia?
A. Confusion
B. Muscle weakness
C. Seizures
D. All of the above
Answer: D
Rationale: Hypernatremia affects neurological and muscular function, potentially
causing all listed symptoms.
A patient is post-op day 1. Which finding is expected?
A. High fever
B. Mild pain at incision
C. Purulent drainage
D. Severe swelling
Answer: B
Rationale: Mild pain is normal after surgery; other findings may indicate complications.