RN Registered Nurse 2 — Questions and Answers
Question 1: A patient receiving IV vancomycin develops flushing, erythema, and hypotension during the infusion. What is the most likely cause?
- Anaphylactic reaction
- Red man syndrome (Correct answer)
- Vancomycin toxicity
- Septic shock
Correct answer: Red man syndrome
Red man syndrome is a rate-related reaction to vancomycin characterized by flushing, erythema, and hypotension that is prevented by slowing the infusion rate.
Question 2: A nurse is preparing to administer digoxin. Which finding should prompt the nurse to withhold the dose and notify the provider?
- Heart rate of 58 bpm
- Blood pressure of 118/72 mmHg
- Serum potassium of 3.2 mEq/L (Correct answer)
- Respiratory rate of 16 breaths/min
Correct answer: Serum potassium of 3.2 mEq/L
Hypokalemia (K+ < 3.5 mEq/L) potentiates digoxin toxicity by increasing myocardial sensitivity to the drug.
Question 3: When performing a focused assessment on a patient with suspected deep vein thrombosis (DVT), which finding is most significant?
- Bilateral lower extremity edema
- Unilateral calf warmth, redness, and tenderness (Correct answer)
- Generalized leg fatigue after ambulation
- Intermittent bilateral calf cramping at night
Correct answer: Unilateral calf warmth, redness, and tenderness
Unilateral calf warmth, redness, and tenderness are classic signs of DVT, distinguishing it from bilateral or systemic causes.
Question 4: A nurse is caring for a patient in sickle cell crisis. Which intervention is the highest priority?
- Administer prescribed analgesics (Correct answer)
- Apply ice packs to painful areas
- Restrict oral fluid intake
- Encourage ambulation every 2 hours
Correct answer: Administer prescribed analgesics
Pain management is the highest priority in sickle cell crisis, as vaso-occlusion causes severe ischemic pain requiring prompt opioid analgesia.
Question 5: A patient with COPD is receiving oxygen therapy. The nurse notes the respiratory rate has dropped to 8 breaths/min. What is the most likely explanation?
- The patient's condition has improved significantly
- High-flow oxygen suppressed the hypoxic drive (Correct answer)
- The patient is experiencing pulmonary hypertension
- Low-flow oxygen caused carbon dioxide retention
Correct answer: High-flow oxygen suppressed the hypoxic drive
Patients with COPD may rely on hypoxic drive for ventilation; high-flow oxygen can suppress this drive and cause respiratory depression.
Question 6: A nurse is caring for a postoperative patient and notes the Jackson-Pratt drain output has suddenly decreased and the site is swelling. What should the nurse do first?
- Increase the patient's IV fluid rate
- Check that the drain bulb is compressed correctly (Correct answer)
- Notify the surgeon immediately
- Apply a pressure dressing over the site
Correct answer: Check that the drain bulb is compressed correctly
A sudden decrease in drain output with site swelling often indicates the bulb is not properly compressed, preventing suction; re-establishing suction resolves the issue.
Question 7: A nurse is educating a patient newly diagnosed with type 2 diabetes about the signs of hypoglycemia. Which symptom should the nurse include?
- Polyuria and polydipsia
- Fruity breath and Kussmaul respirations
- Diaphoresis, tremors, and confusion (Correct answer)
- Dry flushed skin and deep rapid breathing
Correct answer: Diaphoresis, tremors, and confusion
Hypoglycemia presents with adrenergic symptoms (diaphoresis, tremors) and neuroglycopenic symptoms (confusion) due to low blood glucose.
RN Registered Nurse 2
A patient receiving IV vancomycin develops flushing, erythema, and hypotension during the infusion.
What is the most likely cause?