1
Qu
, 2
estion 1
A client prescribed warfarin has an INR of 5.2. Which action should the nurse take first?
A. Administer the next dose as prescribed
B. Prepare to give protamine sulfate
C. Hold the dose and notify the provider
D. Encourage intake of green leafy vegetables
Correct Answer: C. Hold the dose and notify the provider
Rationale: INR >3 increases the risk of bleeding; an INR of 5.2 is dangerously high. The nurse
should hold the dose and contact the provider. Protamine sulfate is the antidote for heparin, not
warfarin.
✅ Question 2
A client is receiving digoxin. Which finding should the nurse report immediately?
A. Pulse rate of 58 bpm
B. Nausea and vomiting
C. Visual disturbances and halos
D. Potassium level of 4.2 mEq/L
Correct Answer: C. Visual disturbances and halos
Rationale: Visual changes such as halos are signs of digoxin toxicity and must be reported. A
low heart rate (below 60) is also concerning but not as specific as visual changes.
, 3
✅ Question 3
A postoperative client refuses to use the incentive spirometer. What is the nurse’s best initial
action?
A. Notify the provider
B. Educate the client on the importance of use
C. Document the refusal
D. Tell the client it’s a physician's order
Correct Answer: B. Educate the client on the importance of use
Rationale: Client education is the first step. Understanding the benefits (e.g., preventing
atelectasis) often increases compliance.
✅ Question 4
A client with diabetes has a fasting blood glucose of 58 mg/dL. What should the nurse do first?
A. Notify the provider
B. Recheck the level in 30 minutes
C. Give 15g of carbohydrate
D. Document and continue monitoring
Correct Answer: C. Give 15g of carbohydrate
Rationale: Blood glucose below 70 mg/dL is hypoglycemia. The nurse should administer a fast-
acting carb immediately to correct it.
, 4
✅ Question 5
Which food choice indicates the client understands dietary teaching for a low-sodium diet?
A. Ham and cheese sandwich
B. Canned soup and crackers
C. Grilled chicken with fresh vegetables
D. Hot dogs and fries
Correct Answer: C. Grilled chicken with fresh vegetables
Rationale: Fresh foods are typically low in sodium. Processed meats, canned items, and fast
food are high in sodium.
✅ Question 6
A client with COPD is receiving oxygen at 4 L/min via nasal cannula. The nurse notes
increasing drowsiness. What action is appropriate?
A. Lower the oxygen to 2 L/min
B. Encourage deep breathing
C. Place in high-Fowler’s position
D. Notify the respiratory therapist
Correct Answer: A. Lower the oxygen to 2 L/min
Rationale: High oxygen flow can suppress the hypoxic drive in COPD patients. Lowering it
prevents CO₂ retention and respiratory depression.
Qu
, 2
estion 1
A client prescribed warfarin has an INR of 5.2. Which action should the nurse take first?
A. Administer the next dose as prescribed
B. Prepare to give protamine sulfate
C. Hold the dose and notify the provider
D. Encourage intake of green leafy vegetables
Correct Answer: C. Hold the dose and notify the provider
Rationale: INR >3 increases the risk of bleeding; an INR of 5.2 is dangerously high. The nurse
should hold the dose and contact the provider. Protamine sulfate is the antidote for heparin, not
warfarin.
✅ Question 2
A client is receiving digoxin. Which finding should the nurse report immediately?
A. Pulse rate of 58 bpm
B. Nausea and vomiting
C. Visual disturbances and halos
D. Potassium level of 4.2 mEq/L
Correct Answer: C. Visual disturbances and halos
Rationale: Visual changes such as halos are signs of digoxin toxicity and must be reported. A
low heart rate (below 60) is also concerning but not as specific as visual changes.
, 3
✅ Question 3
A postoperative client refuses to use the incentive spirometer. What is the nurse’s best initial
action?
A. Notify the provider
B. Educate the client on the importance of use
C. Document the refusal
D. Tell the client it’s a physician's order
Correct Answer: B. Educate the client on the importance of use
Rationale: Client education is the first step. Understanding the benefits (e.g., preventing
atelectasis) often increases compliance.
✅ Question 4
A client with diabetes has a fasting blood glucose of 58 mg/dL. What should the nurse do first?
A. Notify the provider
B. Recheck the level in 30 minutes
C. Give 15g of carbohydrate
D. Document and continue monitoring
Correct Answer: C. Give 15g of carbohydrate
Rationale: Blood glucose below 70 mg/dL is hypoglycemia. The nurse should administer a fast-
acting carb immediately to correct it.
, 4
✅ Question 5
Which food choice indicates the client understands dietary teaching for a low-sodium diet?
A. Ham and cheese sandwich
B. Canned soup and crackers
C. Grilled chicken with fresh vegetables
D. Hot dogs and fries
Correct Answer: C. Grilled chicken with fresh vegetables
Rationale: Fresh foods are typically low in sodium. Processed meats, canned items, and fast
food are high in sodium.
✅ Question 6
A client with COPD is receiving oxygen at 4 L/min via nasal cannula. The nurse notes
increasing drowsiness. What action is appropriate?
A. Lower the oxygen to 2 L/min
B. Encourage deep breathing
C. Place in high-Fowler’s position
D. Notify the respiratory therapist
Correct Answer: A. Lower the oxygen to 2 L/min
Rationale: High oxygen flow can suppress the hypoxic drive in COPD patients. Lowering it
prevents CO₂ retention and respiratory depression.
