RN Registered Nurse 4 — Questions and Answers
Question 1: A nurse is caring for a patient with increased intracranial pressure (ICP). Which nursing position provides the best outcome?
- Supine with head of bed flat
- Head of bed elevated 30 degrees with head midline (Correct answer)
- Trendelenburg position
- Left lateral decubitus position
Correct answer: Head of bed elevated 30 degrees with head midline
Elevating the HOB 30 degrees and keeping the head midline promotes venous drainage from the skull, reducing ICP.
Question 2: A nurse notes a patient on heparin infusion has an aPTT of 180 seconds (therapeutic range 60–100 seconds). What is the priority intervention?
- Continue the infusion and recheck in 4 hours
- Stop the infusion and notify the provider (Correct answer)
- Administer vitamin K as an antidote
- Increase IV fluid rate to dilute the heparin
Correct answer: Stop the infusion and notify the provider
An aPTT of 180 seconds indicates supratherapeutic anticoagulation and bleeding risk; the infusion must be stopped and the provider notified for dose adjustment.
Question 3: A patient with acute pancreatitis is prescribed nothing by mouth (NPO). The patient asks why they cannot eat. What is the nurse's best response?
- 'You need to rest your entire digestive system until you feel better.'
- 'Eating stimulates the pancreas to release enzymes that worsen inflammation.' (Correct answer)
- 'Your labs show your lipase is too high to digest food safely.'
- 'We need to give your intestines time to recover from the infection.'
Correct answer: 'Eating stimulates the pancreas to release enzymes that worsen inflammation.'
Oral intake stimulates pancreatic enzyme secretion, which causes autodigestion and worsens pancreatitis; NPO status allows the pancreas to rest.
Question 4: A nurse is preparing a patient for a colonoscopy. Which finding in the patient's history requires immediate communication to the provider?
- Daily aspirin use for cardiac prophylaxis (Correct answer)
- History of constipation
- Allergy to shellfish
- BMI of 32
Correct answer: Daily aspirin use for cardiac prophylaxis
Antiplatelet agents like aspirin increase bleeding risk during colonoscopy with potential polypectomy; the provider must decide whether to hold the medication.
Question 5: A nurse is performing a newborn assessment and notes the infant's skin is yellow at 10 hours of life. How should the nurse interpret this finding?
- Physiologic jaundice, which is normal in the first 24 hours
- Pathologic jaundice requiring immediate evaluation (Correct answer)
- Normal skin color variation in newborns of certain ethnicities
- Carotenemia from transplacental transfer of maternal vitamins
Correct answer: Pathologic jaundice requiring immediate evaluation
Jaundice appearing within the first 24 hours of life is always pathologic and requires immediate evaluation for conditions such as hemolytic disease.
Question 6: A patient recovering from a total hip arthroplasty (THA) tries to pick up an object from the floor by bending forward at the hip. What should the nurse do?
- Assist the patient to complete the movement safely
- Instruct the patient to stop; hip flexion beyond 90 degrees is restricted (Correct answer)
- Encourage the activity as it promotes range of motion
- Document the movement as a sign of good recovery
Correct answer: Instruct the patient to stop; hip flexion beyond 90 degrees is restricted
After THA, hip flexion beyond 90 degrees is contraindicated to prevent prosthetic dislocation; patients must use adaptive equipment like reachers.
Question 7: A nurse is administering a medication via a nasogastric (NG) tube. Which action is most important before instilling the medication?
- Flush the tube with 30 mL of sterile water
- Verify tube placement by checking gastric pH or x-ray confirmation (Correct answer)
- Crush all tablets and dissolve them together in water
- Clamp the tube for 30 minutes after administration
Correct answer: Verify tube placement by checking gastric pH or x-ray confirmation
Confirming NG tube placement before any instillation prevents aspiration or medication delivery into the lungs.
RN Registered Nurse 4
A nurse is caring for a patient with increased intracranial pressure (ICP).
Which nursing position provides the best outcome?