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1. A nurse is preparing to administer digoxin to a client with heart failure. Before
administering the medication, which assessment is the priority?
A. Measure blood pressure.
B. Assess lung sounds.
C. Check the apical pulse for one full minute.
D. Measure oxygen saturation.
Answer: C. Check the apical pulse for one full minute.
Rationale: Digoxin slows cardiac conduction and decreases heart rate. The nurse should
assess the apical pulse for one full minute before administration. If the pulse is below 60
beats per minute in an adult (or according to the provider's prescribed parameters), the
medication should be withheld, and the healthcare provider should be notified. Although
blood pressure, lung sounds, and oxygen saturation are important assessments, the apical
pulse is the priority because digoxin toxicity and adverse effects commonly involve
bradycardia.
2. A client receiving intravenous vancomycin suddenly develops flushing of the face, neck,
and upper chest. Which action should the nurse take first?
A. Stop the infusion immediately.
B. Slow the infusion rate.
C. Administer epinephrine.
D. Notify the healthcare provider before intervening.
Answer: B. Slow the infusion rate.
Rationale: The client is likely experiencing Red Man Syndrome, an infusion-related reaction
caused by rapid administration of vancomycin rather than a true allergic reaction. Slowing
,the infusion rate usually resolves the symptoms. Future doses should be administered over
at least 60 to 120 minutes. Epinephrine is reserved for anaphylaxis, and stopping the
infusion completely is generally unnecessary unless symptoms are severe.
3. Which laboratory value should the nurse review before administering warfarin?
A. Sodium level
B. White blood cell count
C. International Normalized Ratio (INR)
D. Platelet count
Answer: C. International Normalized Ratio (INR).
Rationale: Warfarin therapy is monitored using the INR, which reflects the medication's
anticoagulant effect. Most therapeutic INR ranges fall between 2.0 and 3.0 for common
indications, though some conditions require a higher range. Reviewing the INR helps
determine whether the medication should be administered safely or whether dosage
adjustments are necessary to minimize bleeding risk.
4. A client taking furosemide reports muscle weakness and leg cramps. Which electrolyte
imbalance should the nurse suspect?
A. Hypercalcemia
B. Hypermagnesemia
C. Hypokalemia
D. Hypernatremia
Answer: C. Hypokalemia.
Rationale: Furosemide is a loop diuretic that promotes potassium excretion by the kidneys.
Muscle weakness, leg cramps, fatigue, and cardiac dysrhythmias are common
manifestations of hypokalemia. Monitoring serum potassium levels and encouraging
potassium-rich foods or supplements, when prescribed, are essential nursing
interventions.
5. A client receiving morphine intravenously becomes difficult to arouse and has a
respiratory rate of 8 breaths per minute. Which medication should the nurse anticipate
administering?
, A. Flumazenil
B. Naloxone
C. Protamine sulfate
D. Vitamin K
Answer: B. Naloxone.
Rationale: Naloxone is an opioid antagonist that rapidly reverses opioid-induced respiratory
depression. Respiratory depression is the most life-threatening adverse effect of opioid
medications. After naloxone administration, the nurse should continue monitoring because
its duration of action may be shorter than that of morphine, potentially requiring additional
doses.
6. Which instruction is most important for a client beginning therapy with lisinopril?
A. Increase dietary sodium intake.
B. Report persistent dry cough.
C. Avoid foods containing vitamin K.
D. Take the medication only when blood pressure is elevated.
Answer: B. Report persistent dry cough.
Rationale: A persistent, nonproductive cough is a common adverse effect of angiotensin-
converting enzyme (ACE) inhibitors such as lisinopril. Clients should report this symptom
because an alternative medication, such as an angiotensin receptor blocker (ARB), may be
prescribed. ACE inhibitors may also increase potassium levels and cause angioedema,
which requires immediate medical attention.
7. Which medication should the nurse question before administering to a client with a
documented allergy to penicillin?
A. Azithromycin
B. Cephalexin
C. Ciprofloxacin
D. Doxycycline
Answer: B. Cephalexin.
Rationale: Cephalexin is a first-generation cephalosporin. Although many clients with
penicillin allergies can safely receive cephalosporins, cross-reactivity is possible,