Critical Care Nursing Practice Questions
2025: Test Bank and Study Reference
A nurse is assessing a postpartum client who delivered 12 hours ago. Which type of lochia does
the nurse expect to observe?
• Lochia rubra
• Lochia serosa
• Lochia alba
• No vaginal discharge
Rationale: Lochia rubra is expected during the first 1–3 days postpartum, appearing bright red.
Lochia serosa (pink/brown) occurs days 4–10. Lochia alba (whitish) occurs around day 10–14.
Absence of discharge this early would be abnormal.
A client in the emergency department presents with chest pain. The electrocardiogram (ECG)
shows ST-segment elevation. What is the nurse’s priority action?
• Prepare the client for discharge
• Administer oxygen therapy
• Place the client in a high-Fowler’s position
• Begin teaching about diet and exercise changes
Rationale: The priority for a client with suspected myocardial infarction and ST elevation is to
improve oxygen delivery—administer oxygen immediately. Positioning helps but is secondary.
Discharge and teaching are inappropriate at this stage.
A nurse is caring for a client receiving heparin therapy. Which laboratory value requires the
nurse’s immediate attention?
, • Hemoglobin 13.8 g/dL (138 g/L)
• Platelets 180,000/μL (180 × 10⁹/L)
• Activated partial thromboplastin time (aPTT) 98 seconds
• White blood cell count 7,000/μL (7 × 10⁹/L)
Rationale: Normal aPTT is 25–35 seconds. Therapeutic range is 1.5–2.5× normal (≈50–70 sec). A
value of 98 seconds indicates dangerously high risk for bleeding. Other labs are within normal
ranges.
A nurse is teaching a client with type 2 diabetes about self-care. Which statement indicates a
need for further teaching?
• “I will check my feet daily for cuts or sores.”
• “I should avoid walking barefoot outside or indoors.”
• “I’ll schedule my eye exam every year.”
• “If I feel shaky, I’ll just lie down until it passes.”
Rationale: Feeling shaky suggests hypoglycemia, which requires immediate glucose intake, not
rest. Daily foot care, avoiding barefoot walking, and annual eye exams are correct practices.
A client taking digoxin reports nausea, blurred vision, and seeing yellow halos. Which lab result
is most important to review?
• Sodium 140 mEq/L (140 mmol/L)
• Potassium 3.0 mEq/L (3.0 mmol/L)
• Digoxin level 2.8 ng/mL
• Calcium 9.5 mg/dL (2.4 mmol/L)
Rationale: Normal digoxin level is 0.8–2.0 ng/mL. A level of 2.8 is toxic, explaining the client’s
symptoms. Hypokalemia (K+ 3.0) increases digoxin toxicity risk but is secondary to confirming
actual toxic level. Sodium and calcium are normal.
,A nurse is preparing to administer furosemide to a client with heart failure. Which assessment is
most important before giving the medication?
• Heart rate
• Respiratory rate
• Serum potassium level
• Capillary refill time
Rationale: Furosemide is a loop diuretic that causes potassium loss. Hypokalemia increases the
risk for life-threatening arrhythmias, so potassium must be checked before administration.
Heart rate and respirations are important but not the immediate safety concern.
A client with chronic kidney disease is prescribed a low-protein diet. What is the primary
purpose of this diet?
• To reduce accumulation of nitrogenous wastes
• To prevent weight loss
• To decrease fluid retention
• To increase urine output
Rationale: A low-protein diet in kidney disease minimizes urea and nitrogenous waste buildup,
easing the workload on damaged kidneys. It does not primarily target weight, fluid, or urine
production.
The nurse is reinforcing education for a client taking warfarin. Which statement indicates correct
understanding?
• “I will increase my green leafy vegetables for extra vitamins.”
• “I will have my blood levels checked regularly.”
• “I should take aspirin if I get a headache.”
• “I can stop taking this medication once I feel better.”
Rationale: Clients on warfarin require regular INR monitoring. Increased leafy vegetables (high
in vitamin K) reduce effectiveness. Aspirin increases bleeding risk. Warfarin is not stopped
without medical direction.
, A nurse is caring for a client with a tracheostomy. The client’s oxygen saturation drops to 85%,
and the tracheostomy tube is dislodged. What is the nurse’s priority action?
• Call the rapid response team
• Insert the obturator and attempt to replace the tracheostomy tube
• Give the client sips of water to stimulate swallowing
• Document the event in the medical record
Rationale: Airway is the top priority. The nurse must immediately reinsert the trach tube using
the obturator. Calling for help is important but comes after restoring the airway. Water intake is
inappropriate, and documentation is never the first step in an emergency.
The nurse is providing care for a client with cirrhosis. Which assessment finding is most
concerning?
• Jaundice
• Ascites
• Asterixis (flapping hand tremors)
• Spider angiomas
Rationale: Asterixis indicates hepatic encephalopathy from increased ammonia levels, a serious
and potentially life-threatening complication of cirrhosis. Jaundice, ascites, and spider angiomas
are expected but less immediately critical.
A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical
ventilation. Which intervention helps prevent the development of a tracheoesophageal fistula?
• Frequent suctioning
• Maintaining cuff pressure
• Maintaining mechanical ventilation settings
• Alternating the use of a cuffed tube with a cuffless tube daily
Rationale: The most important measure is maintaining cuff pressure at the lowest level needed
to prevent air leaks. Excessive cuff pressure causes tracheal wall necrosis, which can lead to a
2025: Test Bank and Study Reference
A nurse is assessing a postpartum client who delivered 12 hours ago. Which type of lochia does
the nurse expect to observe?
• Lochia rubra
• Lochia serosa
• Lochia alba
• No vaginal discharge
Rationale: Lochia rubra is expected during the first 1–3 days postpartum, appearing bright red.
Lochia serosa (pink/brown) occurs days 4–10. Lochia alba (whitish) occurs around day 10–14.
Absence of discharge this early would be abnormal.
A client in the emergency department presents with chest pain. The electrocardiogram (ECG)
shows ST-segment elevation. What is the nurse’s priority action?
• Prepare the client for discharge
• Administer oxygen therapy
• Place the client in a high-Fowler’s position
• Begin teaching about diet and exercise changes
Rationale: The priority for a client with suspected myocardial infarction and ST elevation is to
improve oxygen delivery—administer oxygen immediately. Positioning helps but is secondary.
Discharge and teaching are inappropriate at this stage.
A nurse is caring for a client receiving heparin therapy. Which laboratory value requires the
nurse’s immediate attention?
, • Hemoglobin 13.8 g/dL (138 g/L)
• Platelets 180,000/μL (180 × 10⁹/L)
• Activated partial thromboplastin time (aPTT) 98 seconds
• White blood cell count 7,000/μL (7 × 10⁹/L)
Rationale: Normal aPTT is 25–35 seconds. Therapeutic range is 1.5–2.5× normal (≈50–70 sec). A
value of 98 seconds indicates dangerously high risk for bleeding. Other labs are within normal
ranges.
A nurse is teaching a client with type 2 diabetes about self-care. Which statement indicates a
need for further teaching?
• “I will check my feet daily for cuts or sores.”
• “I should avoid walking barefoot outside or indoors.”
• “I’ll schedule my eye exam every year.”
• “If I feel shaky, I’ll just lie down until it passes.”
Rationale: Feeling shaky suggests hypoglycemia, which requires immediate glucose intake, not
rest. Daily foot care, avoiding barefoot walking, and annual eye exams are correct practices.
A client taking digoxin reports nausea, blurred vision, and seeing yellow halos. Which lab result
is most important to review?
• Sodium 140 mEq/L (140 mmol/L)
• Potassium 3.0 mEq/L (3.0 mmol/L)
• Digoxin level 2.8 ng/mL
• Calcium 9.5 mg/dL (2.4 mmol/L)
Rationale: Normal digoxin level is 0.8–2.0 ng/mL. A level of 2.8 is toxic, explaining the client’s
symptoms. Hypokalemia (K+ 3.0) increases digoxin toxicity risk but is secondary to confirming
actual toxic level. Sodium and calcium are normal.
,A nurse is preparing to administer furosemide to a client with heart failure. Which assessment is
most important before giving the medication?
• Heart rate
• Respiratory rate
• Serum potassium level
• Capillary refill time
Rationale: Furosemide is a loop diuretic that causes potassium loss. Hypokalemia increases the
risk for life-threatening arrhythmias, so potassium must be checked before administration.
Heart rate and respirations are important but not the immediate safety concern.
A client with chronic kidney disease is prescribed a low-protein diet. What is the primary
purpose of this diet?
• To reduce accumulation of nitrogenous wastes
• To prevent weight loss
• To decrease fluid retention
• To increase urine output
Rationale: A low-protein diet in kidney disease minimizes urea and nitrogenous waste buildup,
easing the workload on damaged kidneys. It does not primarily target weight, fluid, or urine
production.
The nurse is reinforcing education for a client taking warfarin. Which statement indicates correct
understanding?
• “I will increase my green leafy vegetables for extra vitamins.”
• “I will have my blood levels checked regularly.”
• “I should take aspirin if I get a headache.”
• “I can stop taking this medication once I feel better.”
Rationale: Clients on warfarin require regular INR monitoring. Increased leafy vegetables (high
in vitamin K) reduce effectiveness. Aspirin increases bleeding risk. Warfarin is not stopped
without medical direction.
, A nurse is caring for a client with a tracheostomy. The client’s oxygen saturation drops to 85%,
and the tracheostomy tube is dislodged. What is the nurse’s priority action?
• Call the rapid response team
• Insert the obturator and attempt to replace the tracheostomy tube
• Give the client sips of water to stimulate swallowing
• Document the event in the medical record
Rationale: Airway is the top priority. The nurse must immediately reinsert the trach tube using
the obturator. Calling for help is important but comes after restoring the airway. Water intake is
inappropriate, and documentation is never the first step in an emergency.
The nurse is providing care for a client with cirrhosis. Which assessment finding is most
concerning?
• Jaundice
• Ascites
• Asterixis (flapping hand tremors)
• Spider angiomas
Rationale: Asterixis indicates hepatic encephalopathy from increased ammonia levels, a serious
and potentially life-threatening complication of cirrhosis. Jaundice, ascites, and spider angiomas
are expected but less immediately critical.
A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical
ventilation. Which intervention helps prevent the development of a tracheoesophageal fistula?
• Frequent suctioning
• Maintaining cuff pressure
• Maintaining mechanical ventilation settings
• Alternating the use of a cuffed tube with a cuffless tube daily
Rationale: The most important measure is maintaining cuff pressure at the lowest level needed
to prevent air leaks. Excessive cuff pressure causes tracheal wall necrosis, which can lead to a
