QUESTION 1
A nurse is preparing to administer warfarin to a client with atrial fibrillation. The client's
laboratory results show an INR of 5.8. Which action should the nurse take?
A) Administer the warfarin as prescribed
B) Hold the warfarin and prepare to administer vitamin K
C) Administer protamine sulfate
D) Hold the warfarin and notify the provider
Correct Answer: B
Rationale: An INR of 5.8 is significantly above the therapeutic range for atrial fibrillation
(2.0-3.0) and indicates a high risk for bleeding. Vitamin K is the specific antidote for
warfarin and should be administered as prescribed to reverse the anticoagulant effect.
Protamine sulfate is the antidote for heparin, not warfarin. The nurse should hold the
warfarin and prepare to administer vitamin K per provider order .
,QUESTION 2
A client with myasthenia gravis reports increased muscle weakness approximately 1
hour after taking pyridostigmine. What should the nurse suspect?
A) Therapeutic response
B) Cholinergic crisis
C) Myasthenic crisis
D) Anaphylactic reaction
Correct Answer: B
Rationale: Pyridostigmine is a cholinesterase inhibitor used to treat myasthenia gravis.
When a client experiences increased muscle weakness shortly after taking the
medication, this suggests cholinergic crisis—an overdose of the medication causing
excessive acetylcholine accumulation at the neuromuscular junction. This is
distinguished from myasthenic crisis, which typically presents with weakness before the
next scheduled dose .
QUESTION 3
A nurse is administering intravenous vancomycin to a client. Which finding requires the
nurse's immediate attention?
A) The client reports mild nausea
B) The client develops flushing and pruritus on the face and neck
C) The client's heart rate is 88 bpm
D) The client's urine output is 35 mL/hr
Correct Answer: B
Rationale: Flushing and pruritus on the face and neck are signs of "Red Man
Syndrome," a histamine-release reaction associated with rapid IV infusion of
,vancomycin. The nurse should slow the infusion rate immediately. While nausea and
heart rate changes may occur, Red Man Syndrome requires priority intervention.
Vancomycin should be infused over at least 60 minutes to prevent this reaction .
QUESTION 4
The nurse is teaching a client with hypertension about a new prescription for ramipril.
Which statement by the client requires follow-up?
A) "I should stop the medication if I develop swelling of my lips or eyes"
B) "I will avoid taking potassium supplements with this medication"
C) "I can continue taking this medication if I become pregnant"
D) "I may develop a dry cough while taking this medication"
Correct Answer: C
Rationale: ACE inhibitors like ramipril are contraindicated during pregnancy due to the
risk of fetal injury and death. They are classified as Pregnancy Category D. The client
should be instructed to notify the provider immediately if pregnancy occurs or is
suspected. Swelling of lips/eyes indicates angioedema requiring discontinuation.
Hyperkalemia is a risk, so potassium supplements should be avoided. A dry cough is a
common side effect but not dangerous .
QUESTION 5
A client is prescribed digoxin for heart failure. Which finding indicates digoxin toxicity?
A) Heart rate of 68 bpm
B) Serum digoxin level of 1.8 ng/mL
, C) Client reports seeing yellow halos around lights
D) Blood pressure of 118/76 mmHg
Correct Answer: C
Rationale: Visual disturbances, particularly seeing yellow or green halos around lights
(xanthopsia), are classic signs of digoxin toxicity. The therapeutic range for digoxin is
0.5-2.0 ng/mL; a level of 1.8 ng/mL is within therapeutic range. A heart rate of 68 bpm is
normal. The nurse should assess for other signs of toxicity including nausea, vomiting,
and cardiac dysrhythmias .
QUESTION 6
A nurse is preparing to administer dopamine IV to a client in shock. What is the priority
assessment before administration?
A) Lung sounds
B) Blood pressure
C) Level of consciousness
D) Urine output
Correct Answer: B
Rationale: Dopamine is a vasopressor that increases blood pressure by causing
vasoconstriction and increasing cardiac output. The priority assessment before
administration is blood pressure to confirm hypotension and establish a baseline for
monitoring treatment effectiveness. While lung sounds, level of consciousness, and
urine output are important assessments, blood pressure is the primary indicator for
dopamine administration and titration .
A nurse is preparing to administer warfarin to a client with atrial fibrillation. The client's
laboratory results show an INR of 5.8. Which action should the nurse take?
A) Administer the warfarin as prescribed
B) Hold the warfarin and prepare to administer vitamin K
C) Administer protamine sulfate
D) Hold the warfarin and notify the provider
Correct Answer: B
Rationale: An INR of 5.8 is significantly above the therapeutic range for atrial fibrillation
(2.0-3.0) and indicates a high risk for bleeding. Vitamin K is the specific antidote for
warfarin and should be administered as prescribed to reverse the anticoagulant effect.
Protamine sulfate is the antidote for heparin, not warfarin. The nurse should hold the
warfarin and prepare to administer vitamin K per provider order .
,QUESTION 2
A client with myasthenia gravis reports increased muscle weakness approximately 1
hour after taking pyridostigmine. What should the nurse suspect?
A) Therapeutic response
B) Cholinergic crisis
C) Myasthenic crisis
D) Anaphylactic reaction
Correct Answer: B
Rationale: Pyridostigmine is a cholinesterase inhibitor used to treat myasthenia gravis.
When a client experiences increased muscle weakness shortly after taking the
medication, this suggests cholinergic crisis—an overdose of the medication causing
excessive acetylcholine accumulation at the neuromuscular junction. This is
distinguished from myasthenic crisis, which typically presents with weakness before the
next scheduled dose .
QUESTION 3
A nurse is administering intravenous vancomycin to a client. Which finding requires the
nurse's immediate attention?
A) The client reports mild nausea
B) The client develops flushing and pruritus on the face and neck
C) The client's heart rate is 88 bpm
D) The client's urine output is 35 mL/hr
Correct Answer: B
Rationale: Flushing and pruritus on the face and neck are signs of "Red Man
Syndrome," a histamine-release reaction associated with rapid IV infusion of
,vancomycin. The nurse should slow the infusion rate immediately. While nausea and
heart rate changes may occur, Red Man Syndrome requires priority intervention.
Vancomycin should be infused over at least 60 minutes to prevent this reaction .
QUESTION 4
The nurse is teaching a client with hypertension about a new prescription for ramipril.
Which statement by the client requires follow-up?
A) "I should stop the medication if I develop swelling of my lips or eyes"
B) "I will avoid taking potassium supplements with this medication"
C) "I can continue taking this medication if I become pregnant"
D) "I may develop a dry cough while taking this medication"
Correct Answer: C
Rationale: ACE inhibitors like ramipril are contraindicated during pregnancy due to the
risk of fetal injury and death. They are classified as Pregnancy Category D. The client
should be instructed to notify the provider immediately if pregnancy occurs or is
suspected. Swelling of lips/eyes indicates angioedema requiring discontinuation.
Hyperkalemia is a risk, so potassium supplements should be avoided. A dry cough is a
common side effect but not dangerous .
QUESTION 5
A client is prescribed digoxin for heart failure. Which finding indicates digoxin toxicity?
A) Heart rate of 68 bpm
B) Serum digoxin level of 1.8 ng/mL
, C) Client reports seeing yellow halos around lights
D) Blood pressure of 118/76 mmHg
Correct Answer: C
Rationale: Visual disturbances, particularly seeing yellow or green halos around lights
(xanthopsia), are classic signs of digoxin toxicity. The therapeutic range for digoxin is
0.5-2.0 ng/mL; a level of 1.8 ng/mL is within therapeutic range. A heart rate of 68 bpm is
normal. The nurse should assess for other signs of toxicity including nausea, vomiting,
and cardiac dysrhythmias .
QUESTION 6
A nurse is preparing to administer dopamine IV to a client in shock. What is the priority
assessment before administration?
A) Lung sounds
B) Blood pressure
C) Level of consciousness
D) Urine output
Correct Answer: B
Rationale: Dopamine is a vasopressor that increases blood pressure by causing
vasoconstriction and increasing cardiac output. The priority assessment before
administration is blood pressure to confirm hypotension and establish a baseline for
monitoring treatment effectiveness. While lung sounds, level of consciousness, and
urine output are important assessments, blood pressure is the primary indicator for
dopamine administration and titration .
