1.

A client is brought to the emergency department states that he has accidentally been taking two times
his prescribed dose of Warfarin (Coumadin). After observing that the client has no evidence of any obvious
bleeding, the nurse should do which of the following?

A. Draw a sample for activated partial thromboplastin time (aPTT) level.

B. Draw a sample for prothrombin time (PT) level and international normalized ratio (INR).
C. Prepare to administer Vitamin K.
D. Prepare to administer Protamine sulfate.

Answer: B. Draw a sample for prothrombin time (PT) level and international normalized ratio (INR).

The next action for the nurse to take is to draw a sample for INR and PT level to check the client’s
anticoagulation status and risk for bleeding. These results will provide information on how to manage the
client either giving an antidote such as Vitamin K or administering a blood transfusion.

Option A: The aPTT determines the effects of heparin therapy.

Option C: The results of the INR and PT level will be needed first.
Option D: Protamine sulfate is the antidote for heparin overdose.

2. A nurse is handling a pregnant client who was prescribed to have an Alpha Feta Protein level. The nurse
should explain to the client that this blood test:

A. Can indicate lung disorders and neural tube defects.

B. Abnormal levels are associated with an increased risk for chromosome abnormality.
C. Once the Alpha Feta Protein levels are abnormal, an amniocentesis will be ordered.
D. An Alpha Feta Protein is a definitive test for neural tube defects.

Answer: C. Once the Alpha Feta Protein levels are abnormal, an amniocentesis will be ordered.

If the Alpha Feta Protein levels are abnormal, the physician will prescribe an amniocentesis to confirm or
eliminate the diagnosis of a neural tube defect.

Option A is incorrect since Alpha Feta Protein does not indicate lung disorders.
Option B is incorrect because an increase of human chorionic gonadotropin instead is associated with an
increased risk for chromosome abnormality.
Option D is incorrect because an Alpha Feta Protein level is a screening test and is not a definitive test.

3. An adult male client has a hemoglobin count of 12.5 g/dL. Based on the result, the client is most likely
having this due to which of the following noted in the client’s record?

A. Emphysema.
B. Client living at a high altitude.
C. Dehydration.
D. History of an enlarged spleen.

Answer: D. History of splenomegaly.

The normal hemoglobin level for an adult male is 14-16.5 g/dL. An enlarged spleen may cause anemia (low
hemoglobin count) in clients.

Options A and B: Emphysema and living at higher altitudes causes the red blood cell production to naturally
increases to compensate for the lower oxygen supply.
Option C: Dehydration may increase the hemoglobin level by hemoconcentration.

4. A screen test for detection of human immunodeficiency virus (HIV) reveals a positive ELISA exam.
Which of the following test will be used to confirm the diagnosis of HIV?

A. Indirect immunofluorescence assay (IFA).

B. CD4-to-CD8 ratio.
C. Radioimmunoprecipitation assay (RIPA) test.
D. p24 antigen assay.

Answer: A. Indirect immunofluorescence assay (IFA)

The indirect immunofluorescence assay (IFA) test and Western Blot test result are considered as
confirmatory for HIV.

Option B: CD4-to-CD8 ratio monitors the progression of HIV.

Option C: Radioimmunoprecipitation assay (RIPA) test detects HIV protein rather than showing antibodies.
Option D: p24 antigen assay quantifies the amount of HIV viral core protein.

5. The client went to the emergency room with a sudden onset of chest pain and difficulty of breathing.
Which of the following result is indicative that the client is experiencing a myocardial infarction?

A. Myoglobin level of 98 mcg/L.

B. Troponin T of 0.09 ng/mL.
C. Troponin I 0.5 ng/mL.
D. Creatine kinase (CK-MB) 155 units/L.

Answer: A. Myoglobin level of 98 mcg/L.

The normal value of myoglobin is lower than 90 mcg/L; An elevation could indicate a myocardial infarction.

Options B, C, and D all have normal values.

6. A nurse is caring for a client with diarrhea and dehydration. The nurse determines that the client has
received adequate fluid replacement if the blood urea nitrogen decreases to:

A. 36 mg/dL.
B. 27 mg/dL.
C. 18 mg/dL.
D. 6 mg/dL.

Answer: C. 18 mg/dL.
The normal value of blood urea nitrogen is 8 to 25 mg/dL.
Options A and B still indicates dehydration.
Option D which has a low BUN occurs with conditions such as fluid volume overload, malnutrition, etc.

7. A client with liver cirrhosis has been advised to follow a high-protein diet. The nurse evaluates the
effectiveness of the diet if the total protein level is which of the following values?

A. 6.9 g/dL.
B. 4.9 g/dL.
C. 2.9 g/dL.
D. 0.9 g/dL.

Answer: A. 6.9 g/dL.

The normal value for total serum protein is 6 to 8 g/dL. The client with liver cirrhosis has low total protein
levels secondary to inadequate nutrition.
Options B, C, and D are abnormal values.

8. The nurse is handling a client with chronic pancreatitis. Upon reviewing the client’s record, which of the
following serum amylase level is to be expected?

A. 50 units/L.
B. 150 units/L.
C. 350 units/L.
D. 650 units/L.

Answer: C. 350 units/L.

The normal serum amylase level is 25 to 151 unit/L. Clients with chronic pancreatitis have an increased
level of serum amylase which does not exceed three times the normal value.

Options A and B are within the normal values.

Option D is seen with acute pancreatitis since the value may exceed five times the normal value.

9. The nurse caring for a client with a serum calcium of 6.8 mg/dL. What would the nurse expect the
change on the electrocardiogram (ECG)?

A. None. This is a normal calcium level.

B. Prolonged QT interval.
C. Shortened ST segment.
D. Widened T wave.

Answer: B. Prolonged QT interval.

The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates
hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged
ST or QT interval.

Options C and D: A shortened ST segment and a widened T wave occur with hypercalcemia.
10. When providing care for a female client with Addison disease, the nurse should be alert for which of the
following laboratory value?

A. Potassium level of 3.2 mEq/L.

B. Calcium level of 3.3 mEq/L.
C. Sodium level of 150 mg/dL.
D. Hematocrit level of 25%.

Answer: D. Hematocrit level of 25%.

A client with Addison’s disease is at risk for anemia. The normal hematocrit level of a female adult is 35%
to 45%. A client with anemia has a low hematocrit level.
Options A and B: Client with Addison’s disease have an increased potassium and calcium level.
Option C: Client with Addison’s disease have a low sodium level.

11. A female client went to the clinic with a creatine clearance of 200 mL/min. Which of the following
condition of the client can cause the increased level of this test?

A. Renal disease.
B. Dehydration.
C. Congestive heart failure.
D. History of high dietary protein intake.

Answer: D. History of high dietary protein intake.

The normal creatine clearance for a female is 88 to 128 ml/min. An increased creatinine clearance is often
referred to as hyperfiltration and is most commonly seen during pregnancy or in clients with a large dietary
protein intake.

Options A, B, and C are seen with a decreased creatinine clearance.

12. A nurse is reviewing the complete blood count (CBC) of a child who has been diagnosed with idiopathic
thrombocytopenic purpura. Which of the following laboratory result should the nurse report immediately to
the physician?

A. Platelet count of 30,000/mm3.

B. Hemoglobin level of 7.5 g/dL.
C. Reticulocyte count of 6.5%.
D. Eosinophil count of 700 cells/mm3.

Answer: B. Hemoglobin level of 7.5 g/dL.

The low hemoglobin level indicates that the client has an active bleeding, and immediate actions such as
additional diagnostic exam and blood transfusions can be suggested.

Options A, C, and D: Decreased platelet count, increased reticulocyte and increased eosinophil count are
expected in a child with idiopathic thrombocytopenic purpura.
13. A client with Congestive heart failure is about to take a dose of furosemide (Lasix). Which of the
following potassium level, if noted in the client’s record, should be reported before giving the due
medication?

A. 5.1 mEq/L.
B. 4.9 mEq/L.
C. 3.9 mEq/L.
D. 3.3 mEq/L.

Answer: D. 3.3 mEq/L.

The normal potassium level is 3.5 to 5.5 mEq/L. Low potassium levels can be dangerous, especially for
people with CHF. Low potassium can cause fatal heart arrhythmias.

14. Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which
abnormal laboratory results should the nurse report? Select all that apply.
1.Calcium, 7 mg/dL
2. Magnesium, 1 mg/dL
3. Phosphorus, 3.6 mg/dL
4. Neutrophils, 1000 cells/mm3
5. Serum creatinine, 1 mg/dL
6. White blood cells, 3000 cells/mm3

Answer: 1, 2, 4, 6. Rationale- The normal values include the following: calcium, 8.6 to 10 mg/dL;
magnesium, 1.6 to 2.6 mg/dL; phosphorus 2.7 to 4.5 mg/dL; neutrophils, 1800 to 7800 cells/mm3; serum
creatinine, 0.6 to 1.3 mg/dL; and white blood cells, 4500 to 11,000 cells/mm3. The calcium level noted is
low; the magnesium level noted is low; the phosphorus level noted is normal; the neutrophil level noted is
low; the serum creatinine level noted is normal; and the white blood cell level is low.

15. A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. The nurse
should take which action after seeing the laboratory results?
A. Report the abnormally low count
B. Report the abnormally high count
C. Place the client on bleeding precautions
D. Place the normal report in the client's medical record

Answer: D. Rationale- A normal platelet count ranges from 150,000 to 400,000 cells/mm3. The nurse
should place the report containing the normal laboratory value in the client's medical record. A platelet
count of 300,000 cells/mm3 is not an elevated count. The count also is not low; therefore bleeding
precautions are not needed.

16. The nurse checks the laboratory result for a serum digoxin level that was prescribed for a client earlier
in the day and notes that the result is 2.4 ng/mL. The nurse should take which immediate action?
A. Check the client's last pulse rate
B. Notify the health care provider
C. Record the normal value on the client's flow sheet
D. Administer the next dose of the medication as scheduled
Answer: B.Rationale- The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A level of 2.4 ng/mL
exceeds the therapeutic range and indicates toxicity. The nurse should notify the HCP, who may give
further prescriptions about holding further doses of digoxin. The option that indicates to record the normal
value on the client's flow sheet is incorrect because the level is not normal. The next dose should not be
administered because the serum digoxin level exceeds the therapeutic range. Checking the client's last
pulse rate may have limited value in this situation. Depending on the time that has elapsed since the last
assessment, a current assessment of the client's status may be more useful.

17. A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse
determines that the client has received adequate volume replacement if the blood urea nitrogen level drops
to which value?
A. 3 mg/dL
B. 15 mg/dL
C. 29 mg/dL
D. 35 mg/Dl

Answer: B. Rationale-The normal blood urea nitrogen level is 8 to 25 mg/dL. Values of 29 mg/dL and 35
mg/dL reflect continued dehydration. A value of 3 mg/dL reflects a lower than normal value, which may
occur with fluid volume overload, among other conditions.

18. A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A
troponin T blood specimen is obtained and the results indicate a level of 0.6 ng/mL. The nurse determines
that this result indicates which finding?
1. A normal level
2. A low value that indicates possible gastritis
3. A level that indicates a myocardial infarction
4. A level that indicates the presence of possible angina

Answer: C. Rationale- Troponin is a regulatory protein found in striated muscle. The troponins function
together in the contractile apparatus for muscle in skeletal muscle and in the myocardium. Increased
amounts of troponins are released into the bloodstream when an infarction causes damage to the
myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial
infarction. A normal troponin I level is lower than 0.6 ng/mL.

19. A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis.
The client's activated partial thromboplasm (aPTT) time is 65 seconds. The nurse anticipates that which
action is needed?
A. Discontinuing the heparin infusion
B. Increasing the rate of the heparin infusion
C. Decreasing the rate of the heparin infusion
D. Leaving the rate of the heparin infusion as is

Answer: D. Rationale- The normal aPTT varies between 20 and 36 seconds, depending on the type of
activator used in testing therapeutic dose of heparin for treatment of deep vein thrombosis is to the keep
the aPTT between 1.5 and 2.5 times normal. This means that the client's value should not be less than 30
seconds or greater than 90 seconds. Thus the client's aPTT is within the therapeutic range and the dose
should remain unchanged.
20. A client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). Which serum
potassium level, if noted in the client's laboratory report, should be reported before administering the dose
of furosemide?
1. 3.2 mEq/L
2. 3.8 mEq/L
3. 4.2 mEq/L
4. 4.8 mEq/L

Answer: A. Rationale- The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L. The correct
option is the only value that falls below the therapeutic range. Administering furosemide to a client with low
potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining
options are within the normal range.

21. An adult client with cirrhosis has been prescribed a diet with optimal amounts of protein. The nurse
evaluates the client's status as being most satisfactory if the total protein is which value?
A. 0.4 g/dL
B. 3.7 g/dL
C. 6.4 g/dL
D. 9.8 g/dL
Answer: C. Rationale- The normal range for total serum protein level in the adult client is 6 to 8 g/dL. The
client with cirrhosis often has low total protein levels as a result of inadequate nutrition.
Excess protein is not helpful, though, because a function of the liver is to metabolize protein. A diseased
liver may not metabolize protein well.
The options of 0.4 g/dL. and 3.7 g/dL identify low values, and 9.8 g/dL identifies a high protein value.

22. A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 9%. On the basis of this test
result, the nurse plans to teach the client about the need for which measure?
A. Avoiding infection
B. Taking in adequate fluids
C. Preventing and recognizing hypoglycemia
D. Preventing and recognizing hyperglycemia
Answer: D.Rationale- In the test result for glycosylated hemoglobin A1C 7% or less indicates good control,
7% to 8% indicates fair control, and 8% or higher indicates poor control. This test measures the amount of
glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in
the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in
identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate
continued need for teaching related to the prevention of hyperglycemic episodes.

23. The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would
consider implementing neutropenic precautions if the client's white blood count was which value?
A. 2000 cells/mm3
B. 5800 cells/mm3
C. 8400 cells/mm3
D. 11,500 cells/ mm3
Answer: A. Rationale- The normal white blood cell count ranges from 4500 to 11,000/mm3. The client who
has a decrease in the number of circulating white blood cells is immunesupressed. The nurse implements
neutropenic precautions when the client's value fall sufficiently below the normal level. The specific value
for implementing neutropenic precautions usually is determined by agency policy.
The remaining options are normal values.

24. A client brought to the emergency department states that he has accidentally been taking two times his
prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of
obvious bleeding, the nurse plans to take which action?
A. Prepare to administer an antidote
B. Draw a sample type and crossmatch and tranfuse the client
C. Draw a sample for an activated partial thromboplastin time (aPTT) level
D. Draw a sample for prothrombin time (PT) and international normalized ratio (INR)
Answer: D. Rationale- The next action is to draw a sample for PT and INR level to determine the client's
anticoagulation status and risk for bleeding. These results will provide information as to how to best treat
this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the
effects of heparin therapy.

25. The nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse
anticipates the client's serum amylase level to be which value?
A. 45 units/L
B. 100 units/L
C. 300 units/L
D. 500 units/L
Answer: C. Rationale- The normal serum amylase level is 25 to 151 units/L. With chronic cases of
pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In
acute pancreatitis, the value may exceed five times the normal value. The options of 45 units/L and 100
units/L are within normal limits. The option of 500 units/L is an extremely elevated level seen in acute
pancreatitis.

26. An adult female client has a hemoglobin level of 10.8 g/dL. he nurse interprets that his result is most
likely caused by which condition noted in the client's history?
A. Dehydration
B. Heart failure
C. Iron deficiency anemia
D. Chronic obstructive pulmonary disease
Answer: C. Rationale- The normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron
deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin levels
by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the
hemoglobin level as a result of the body's need for more oxygen carrying capacity.

27. A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. The nurse
should take which action after seeing the laboratory results?
A. Report the abnormally low count
B. Report the abnormally high count
C. Place the client on bleeding precautions
D. Place the normal report in the client's medical record
Answer: D. Rationale- A normal platelet count ranges from 150,000 to 400,000 cells/mm3. The nurse
should place the report containing the normal laboratory value in the client's medical record. A platelet
count of 300,000 cells/mm3 is not an elevated count. The count also is not low; therefore bleeding
precautions are not needed.

28. Which of the following laboratory results indicates hypoparathyroidism?

A. Serum potassium of 3.6 mEq/L.

B. Serum calcium level of 4.3 mEq/L.
C. Serum phosphorus level of 5.7 mg/dL.
D. Serum magnesium level of 1.7 mg/dL.

Answer: C. Serum phosphorus level of 5.7 mg/dL.

The parathyroid is responsible for the absorption of calcium and phosphorus. When a client has
hypoparathyroidism, the serum calcium levels are low and the serum phosphorus levels are high. The
normal phosphorus level is 2.7 to 4.5 mg/dL.

29. A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 10%. Based on the result, the
nurse plans to teach the client about the importance of:

A. Maintaining the result.

B. Preventing hypoglycemia.
C. Preventing hyperglycemia.
D. Avoiding infection.

Answer: C. Preventing hyperglycemia.

Glycosylated hemoglobin A1c level of 8% higher indicates a poor diabetic control. Elevations indicate
continued need for a teaching related to the prevention of hyperglycemic episodes.

30. A client went to the emergency room with sudden onset of high fever and diaphoresis. Serum sodium
was one of the laboratory test taken. Which of the following values would you expect to see?

A. 130 mEq/L.
B. 148 mEq/L.
C. 143 mEq/L.
D. 139 mEq/L.

Answer: B. 148 mEq/L.

The normal sodium level is 135-145 mEq/L. Diaphoresis and a high fever can lead to free water loss
through the skin, resulting in increased sodium level (hypernatremia).

31. A female client went to the clinic with a creatine clearance of 200 mL/min. Which of the following
condition of the client can cause the increased level of this test?

A. Renal disease.
B. Dehydration.
C. Congestive heart failure.
D. History of high dietary protein intake.

Answer: D. History of high dietary protein intake.

The normal creatine clearance for a female is 88 to 128 ml/min. An increased creatinine clearance is often
referred to as hyperfiltration and is most commonly seen during pregnancy or in clients with a large dietary
protein intake.

Options A, B, and C are seen with a decreased creatinine clearance.

32. You’re assessing your patient’s morning labs. The metabolic panel shows the following results below.
Which results are abnormal? Select all that apply:

A. Potassium 2 mEq/L
B. Sodium 110 mEq/L
C. BUN 10
D. Magnesium 2.3 mg/dL
E. Phosphorus 1 mg/dL
F. Glucose 96 mg/dL
G. Creatinine 5 mg/dL

The answers are A, B, E, and G….a normal potassium level is 3.5-5 mEq/L, Sodium 135-145 mEq/L,
phosphorus 2.5-4.5 mg/dL, and creatinine 0.6-1.2 mg/dL

33. A patient’s lipid panel results are back. You’re providing education to the patient on how to improve the
results. Which results below do the patient need to improve on? Select all that apply:

A. LDL 210 mg/dL

B. HDL 40 mg/dL
C. Total Cholesterol 120 mg/dL
D. Triglycerides 375 mg/dL

The answers are A, B, and D. A normal LDL should be LESS than 100 mg/dL, HDL GREATER than 60
mg/dL, and triglycerides <150 mg/dL

34. A 37-year-old female has received 2 units of packed red blood cells. What is the desired hemoglobin
level range for this patient?
A. 42-52%
B. 37-47%
C. 12-16 g/dL
D. 14-18 g/dL

The answer is C. Females should have a hemoglobin range of 12-16 g/dL. Men should have a hemoglobin
range of 14-18 g/dL. Options A and B are the measurement hematocrit ranges (option A is for a male and
option B is for a female).

35. Which patient below is experiencing leukopenia based on their complete blood count?
A. A patient with a platelet level of 100,000.
B. A patient with a WBC level of 9,000.
C. A patient with a platelet level of 150,000.
D. A patient with a WBC level of 3,000.

The answer is D. Leukopenia is defined as a LOW WBC count. A normal WBC count is 5,000-10,000. A
WBC level of 3,000 indicates leukopenia.
36. Which patient below is experiencing thrombocytopenia based on their complete blood count?
A. A patient with a WBC level of 15,000.
B. A patient with a platelet level of 100,000.
C. A patient with a WBC level of 4,000.
D. A patient with a platelet level of 350,000.

The answer is B. Thrombocytopenia is defined as a LOW platelet count. A normal platelet count is 150,000-
400,000. A platelet level of 100,000 indicates thrombocytopenia.

37. A male patient’s complete blood count results are back from this morning’s lab draw. Select all the
NORMAL results:
A. RBC 4.8 million
B. WBC 10,000
C. Platelets 350,000
D. Hbg 12 g/dL
E. Hematocrit 37%

The answers are A, B, and C. Option D and E are NORMAL results for a FEMALE but not a male. A male’s
hemoglobin should be 14-18 g/dL and hematocrit 42-52%.

38. A patient is taking Warfarin (Coumadin). What is a desired INR level for this patient?
A. Less than 1
B. 1.5-2.5 times the normal range
C. 2-3
D. 30-40 seconds

The answer is C: 2-3

39. What is a NORMAL aPTT for a patient who is NOT taking an anticoagulant?
A. 60-80 seconds
B. 2-3
C. 10-12 seconds
D. 30-40 seconds

The answer is D: 30-40 seconds

40. A patient is on a continuous IV Heparin drip for the treatment of a pulmonary embolism. The patient’s
aPTT should be _____________ to ensure that the medication is successful in treating the patient’s
condition.
A. Less than 1
B. 2-3 seconds
C. 1.5-2.5 times the normal range
D. 30-40 seconds
The answer is C. A NORMAL aPTT is 30-40 seconds in someone who is NOT taking Heparin. However, in
order for Heparin to be therapeutic for the treatment of blood clots, the aPTT should be 1.5-2.5 times the
normal range…which is about 60-80 seconds.

41. A patient is on continuous BiPap and has arterial blood gases (ABGs) drawn. Select ALL the abnormal
results:
A. pH 7.20
B. PCO2 48
C. HCO3 25
D. pO2 80

The answers are A and B. A normal pH is 7.35-7.45, and a normal pCO2 is 35-45. A HCO3 should be 22-
26, and pO2 80-100%.

42. A patient has the following arterial blood gases (ABGs). How do you interpret these results: pH 7.38,
HCO3 24, and PCO2 38:
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Normal

The answer is D. These ABGs are normal. A normal pH is 7.35-7.45, and a normal pCO2 is 35-45. A HCO3
should fall between 22-26.

43. A patient is scheduled to take a dose of Digoxin. The patient’s Digoxin level is 1 ng/mL. After checking
the apical pulse, you will?
A. Hold the dose
B. Notify the physician
C. Administer the dose
D. Redraw the level

The answer is C. A normal Digoxin level is 0.5-2 ng/mL. This level is normal; therefore, the nurse should
administer the dose.

44. A nurse just started a blood transfusion for a patient with a Hemoglobin of 6. The patient says, "I feel
hot, my stomach hurts, and I am having difficulty breathing." What should be the nurses first action?
a. Notify the physician immediately
b. Stop the infusion
c. Take vital signs
d. Call a code

Answer: B. The first action should be to stop the transfusion immediately once the patient complains of any
unusual symptoms. The patient is reporting symptoms of a transfusion reaction therefore the transfusion
should be stopped to prevent the patient from worsening. The provider should be notified immediately after
stopping the transfusion. Vital signs should be taken as quickly as possible or as instructed by the provider
after the transfusion has been stopped and the physician has been notified.
A code should be called if the patient becomes unresponsive. A rapid response could be called if the
patient is at risk of destabilizing.

45. Which of the following lab tests would be considered Point of Care testing?
a. Urinalysis
b. Sputum Culture
c. Complete Metabolic Panel
d. Blood Glucose

Answer: B, a Blood Glucose would be considered a Point of Care test as the test can be completed at the
bedside with the result given immediately.
A Urinalysis, Sputum Culture, or Complete Metabolic Panel would not be considered Point of Care tests
because these tests need to be run in a laboratory setting with specialized equipment not available at the
bedside.

46. A patient is being discharged with a new diagnosis of Congestive Heart Failure. Which of the following
statements made by the patient indicate understanding of the diagnosis?
a. "I can drink as much fluid as I want."
b. "I should notify my doctor if my feet start to swell."
c. "Weight gain of 3-5 lbs in one day is to be expected."
d. "It is normally to have difficulty breathing at night."

Answer: B The patient should notify the physician if edema starts developing in the lower extremities. This
indicates more pressure on the heart and can cause complications.
Patients with Congestive Heart Failure need to have a limited fluid intake, typically around 2 L per day to
prevent fluid overloading. The patient should be aware this includes all types of fluids, not just water.
Weight gain of 3-5 lbs in one day should be reported to the physician as this is a significant weight increase
and may indicate fluid retention. The patient's medications may need to be adjusted. The patient
complaining of difficulty breathing at night is experiencing pulmonary edema, a condition in which fluid
builds up into the lungs. This symptom should be reported to the physician immediately.

47. A nurse working in the telemetry unit receives a call that a patient's EKG rhythm has transitioned into
Atrial Fibrillation. Which medication is the patient likely to receive long-term in relation to this diagnosis?
a. Warfarin
b. Heparin
c. Furosemide
d. Albuterol

Answer: A. Warfarin is a common medication given long-term in the management of Atrial Fibrillation to
prevent the development of blood clot, or thromboses, that can cause blockages in the heart or lungs.
Heparin, while used to prevent thrombosis in Atrial Fibrillation, is not usually administered long-term as it is
an IV or Sub-cutaneous injection. Furosemide is given as a diuretic in decreasing fluid retention. It is
normally given to patients with Congestive Heart Failure. Albuterol is typically a drug that is inhaled in the
treatment of Chronic Obstructive Pulmonary Medication or Asthma as a rescue medication. It is
contraindicated in Atrial Fibrillation.
48. A patient has Incentive Spirometry ordered QID x 10 breaths after a cholecystectomy. The patient is
asking why they need to perform this action. Which of the following would Not be a reason the patient
should use the Incentive Spirometer?
a. To decrease lung capacity
b. To gently exercise the lungs
c. To improve recovery time
d. To prevent pneumonia

Answer: A. Using an Incentive Spirometer will increase lung capacity, opening the bronchioles, and
allowing for better oxygenation throughout the body.
Using an Incentive Spirometer gently exercises the lungs and will encourage the patient to take long and
deep breaths instead of short and shallow breaths which are common following surgery. Maintaining
adequately expanded lungs and allow better oxygenation through the blood stream will improve recovery
times, allowing for the patient to start ambulating sooner as well as encourage proper healing to the
surgical site. Incentive Spirometry use prevents pneumonia be keeping bronchioles open and clear,
minimizing the sustainable environment for pneumonia to develop

49. A patient is not to eat or drink anything 24 hours before a colonoscopy.

A. True
B. False

Answer: B. A patient may be instructed to not eat any solid foods up to 24 hours prior to a colonoscopy,
however clear liquids are typically allowed until midnight prior to the procedure up to a couple hours prior to
the procedure. The nurse will need to verify the orders given by the physician.

50. A nurse is reviewing the complete blood count (CBC) of a child who has been diagnosed with idiopathic
thrombocytopenic purpura. Which of the following laboratory result should the nurse report immediately to
the physician?

A. Platelet count of 30,000/mm3.

B. Hemoglobin level of 7.5 g/dL.
C. Reticulocyte count of 6.5%.
D. Eosinophil count of 700 cells/mm3.

Answer: B. Hemoglobin level of 7.5 g/dL.

The low hemoglobin level indicates that the client has an active bleeding, and immediate actions such as
additional diagnostic exam and blood transfusions can be suggested.

Options A, C, and D: Decreased platelet count, increased reticulocyte and increased eosinophil count are
expected in a child with idiopathic thrombocytopenic purpura.