NCLEX High-Alert Medications questions
The PrepScore bank has 105 High-Alert Medications questions, each with a rationale and two tags: the Client Needs category from the test plan and the clinical judgment step it tests. In this topic the items lean on Take action and Analyze cues, which is worth knowing before you practise it. Three worked samples are below, answers behind a reveal.
ISMP high-alert med safety: heparin, warfarin, insulin, opioids, KCl, chemo, vasopressors, NMBs, propofol, digoxin. Independent double-check + reversal + monitoring.
Three worked questions
Q1. A pt on IV heparin for 5 days shows platelets dropped from 245 to 110 + new R calf swelling. The PRIORITY action is:
- A. Continue heparin and observe
- B. Decrease heparin rate
- C. Switch to LMWH (enoxaparin)
- D. STOP all heparin + start argatroban + send HIT antibody
Show answer and rationale
Answer: STOP all heparin + start argatroban + send HIT antibody
HIT type II: >50% platelet drop day 5-10 + thrombosis. STOP ALL heparin including LMWH; non-heparin anticoagulant.
Q2. Which agents are acceptable to use in a pt with confirmed HIT? Select all that apply.
- A. Argatroban
- B. Bivalirudin
- C. Fondaparinux (off-label use)
- D. Enoxaparin (LMWH)
- E. Unfractionated heparin
- F. Heparin flushes for IV lines
Show answer and rationale
Answer: ArgatrobanBivalirudinFondaparinux (off-label use)
HIT requires non-heparin alternatives. All heparin products (including LMWH + flushes) must be avoided.
Q3. The PRIMARY purpose of protamine sulfate is to reverse:
- A. Warfarin
- B. Heparin
- C. Dabigatran
- D. Apixaban
Show answer and rationale
Answer: Heparin
Protamine 1 mg per 100 units heparin in last 4 hr. Not effective for warfarin (vit K) or DOACs.
The rules that decide these questions
From the pack's rule cards — the reasoning shortcuts a wrong answer usually means you were missing.
Therapeutic aPTT 1.5-2.5x baseline. HIT = >50% platelet drop on day 5-10 (+ paradoxical thrombosis). STOP ALL heparin including flushes + LMWH. Use argatroban/bivalirudin. Protamine 1 mg per 100 units in last 4 hr.
AFib INR 2-3; mechanical valve 2.5-3.5. Bactrim/FQ/amiodarone/APAP chronic raise INR; rifampin/phenytoin/St John's wort/high vit K lower INR. Minor bleed = hold + low-dose oral vit K. Major bleed = IV vit K + 4F-PCC.
Lispro WITH meal; regular 30 min BEFORE meal; NPH peaks 4-12 hr; glargine basal no peak no mix. Insulin shifts K+ INTRACELLULAR — replace K+ before giving in hypokalemia. Drip → SC overlap 1-2 hr. Independent double-check.
Monitor sedation (POSS) + RR + SpO2 (capnography in high-risk). Sedation precedes RR depression. PCA by proxy = unsafe — pt only presses. Naloxone 0.04-0.4 mg IV titrated; short half-life — repeat as needed. Multimodal analgesia.
Peripheral KCl ≤ 10 mEq/hr + ≤ 40 mEq/L. Faster/concentrated rates need CENTRAL line + closer monitoring. NEVER IV push (fatal arrhythmia). Continuous ECG. Replace Mg+ alongside. Independent double-check + dedicated pump.
Vesicants (DOX, vincristine): STOP + ASPIRATE WITH IV in place + antidote (dexrazoxane DOX; hyaluronidase vinca). Drug-specific compress (cold for DOX, warm for vinca). Neutropenic precautions when ANC < 500. Body fluids hazardous 48 hr.
Practise the whole pack, tagged and explained
Every item carries its Client Needs category and clinical judgment step, so a wrong answer names the step that failed.
Frequently asked questions
How many High-Alert Medications questions does the bank have?
105 multiple-choice items, plus 10 unfolding cases in the High-Alert Medications pack, each with a rationale.
Are the samples real bank items?
Yes — the three questions above are drawn from the live bank, with their real rationales and tags.
Which clinical judgment steps does this topic train?
Most items in this topic test Take action and Analyze cues, though every step appears.
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