Question: Based on the assessment findings, what actions must the nurse take?
Answer Options:
Place the patient in semi-Fowler’s position, Check vital signs at least every 15 minutes, Obtain a STAT order for an IV normal saline bolus, Notify the provider, Call a code blue, Administer supplemental oxygen
Answer: Check vital signs at least every 15 minutes, Obtain a STAT order for an IV normal saline bolus, Notify the provider, Administer supplemental oxygen
Question: Which of the following are exclusion criteria for thrombolytic therapy in acute ischemic stroke (AIS)? Select all that apply.
Answer Options:
A. History of intracranial hemorrhage B. Blood pressure greater than 160/90 mm Hg C. Last dose of a direct oral anticoagulant (DOAC) less than 72 hours ago D. Symptom onset > 4.5 hours E. Active internal bleeding
Answer: A, D, E (History of intracranial hemorrhage, Symptom onset > 4.5 hours, Active internal bleeding)
Question: What is the most appropriate duration for anticoagulation for HS?
Answer Options:
A. 3 months
B. 6 months
C. 12 months
D. Extended-phase, with annual reevaluation
Answer: A. 3 months
Question: Which ABG value does the nurse expect to see?
Answer Options:
Increased pH with decreased PaO2 and increased PaCO2, Decreased pH with decreased PaO2 and increased PaCO2, Normal pH with decreased PaO2 and normal PaCO2, Normal pH with decreased PaO2 and decreased PaCO2
Answer: Decreased pH with decreased PaO2 and increased PaCO2
Question: The nurse recognizes the patient’s risk for hypovolemic shock. Which baseline indicator will allow the nurse to recognize early signs of shock?
Answer Options:
A. Heart rate, B. Pulse oximetry, C. Skin color, D. Level of consciousness
Answer: A. Heart rate
Question: HS has been on warfarin for 6 weeks and is presenting for his ambulatory care INR check today. His current warfarin regimen is 5 mg daily and he has 5 mg tablets. He is very adherent and takes his warfarin daily at 9:00 PM. He states he recently made the decision to follow a vegetarian diet.
His INR trend is:
4 weeks ago: 2.2
2 weeks ago: 2.0
1 week ago: 1.8
Today: 1.8
What is the best recommendation for HS today?
Answer Options:
A. Hold warfarin today
B. Continue warfarin 5 mg daily
C. Change to warfarin 2.5 mg on Monday, Wednesday, and Friday, and 5 mg on all other days of the week
D. Change to warfarin 7.5 mg on Wednesday, and 5 mg on all other days of the week
E. Change to warfarin 5 mg on Tuesday and Thursday, and 7.5 mg on all other days of the week
Answer: E. Change to warfarin 5 mg on Tuesday and Thursday, and 7.5 mg on all other days of the week
Question: What is the best initial treatment plan for this patient’s electrolyte disorders? Select all that apply. Hint: Choose only PO or IV for each appropriate electrolyte disorder.
Answer Options:
A. Calcium gluconate IV 2 grams x 1 dose B. Potassium chloride PO 40 mEq x 1 dose C. Potassium chloride IV 10 mEq every 1 hour x 10 doses D. K-Phos® PO 250 mg x 1 dose E. Magnesium sulfate IV 4 grams x 1 dose F. Magnesium oxide PO 400 mg x 1 dose
Answer: C, E (Potassium chloride IV 10 mEq every 1 hour x 10 doses, Magnesium sulfate IV 4 grams x 1 dose)
Question: Which of the following treatments are most appropriate for this patient’s acute hyperkalemia? Select all that apply.
Answer Options:
A. Lokelma® B. Furosemide IV C. Calcium gluconate IV D. Kayexalate® E. Regular insulin IV + 50% dextrose IV
Answer: C, E (Calcium gluconate IV, Regular insulin IV + 50% dextrose IV)
Question: Which IV therapy would result in the greatest increase in oxygen-carrying capacity for this patient?
Answer Options:
A. Lactated Ringer’s solution, B. Packed red blood cells, C. Fresh frozen plasma, D. Hetastarch
Answer: B. Packed red blood cells
Question: Which of the following are the appropriate safety monitoring parameters for enoxaparin? Select all that apply.
Answer Options:
A. Hemoglobin B. INR C. Platelets D. Serum creatinine E. aPTT
Answer: A, C, D (Hemoglobin, Platelets, Serum creatinine)
Question: What is the best initial medication regimen recommendation for HS at this time? (Provide drug name and administration route only)
Answer Options:
No answer options provided.
Answer: Unfractionated heparin intravenous (IV)