WITH DETAILED RATIONALES - SENECA COLLEGE
1. A patient with heart failure is prescribed digoxin. Which assessment
finding indicates potential digoxin toxicity?
A. Heart rate of 72 beats per minute
B. Serum potassium level of 4.2 mEq/L
C. Visual disturbances such as yellow halos around lights
D. Blood pressure of 130/80 mmHg
Answer: C. Visual disturbances such as yellow halos around lights
Rationale: Visual disturbances, including yellow or green halos around
lights, blurred vision, and photophobia, are classic signs of digoxin
toxicity. A normal heart rate and potassium level do not indicate
toxicity, and the blood pressure is within acceptable range.
2. A patient is prescribed furosemide (Lasix) for heart failure. Which
laboratory value should the nurse monitor most closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Answer: B. Serum potassium
,Rationale: Furosemide is a loop diuretic that causes significant
potassium wasting. Hypokalemia is a common and potentially
dangerous adverse effect that can lead to cardiac arrhythmias,
especially in patients also taking digoxin.
3. A patient with atrial fibrillation is prescribed amiodarone. Which
adverse effect requires immediate nursing intervention?
A. Blue-gray skin discoloration
B. Pulmonary toxicity with crackles and dyspnea
C. Corneal microdeposits
D. Photosensitivity
Answer: B. Pulmonary toxicity with crackles and dyspnea
Rationale: Pulmonary toxicity is a serious and potentially fatal adverse
effect of amiodarone. Signs include crackles, dyspnea, cough, and
decreased oxygen saturation. This requires immediate discontinuation
and medical evaluation. The other options are also adverse effects but
are less immediately life-threatening.
4. A patient is receiving heparin infusion for deep vein thrombosis.
Which laboratory test is used to monitor therapeutic effectiveness?
A. PT (Prothrombin Time)
B. INR (International Normalized Ratio)
C. aPTT (Activated Partial Thromboplastin Time)
D. Platelet count
Answer: C. aPTT (Activated Partial Thromboplastin Time)
,Rationale: aPTT is the primary laboratory test used to monitor heparin
therapy. The therapeutic range is typically 1.5 to 2.5 times the normal
control value. PT and INR are used to monitor warfarin therapy, while
platelet count monitors for heparin-induced thrombocytopenia.
5. A patient with heart failure is prescribed carvedilol. Which
statement indicates the patient understands the medication teaching?
A. "I can stop this medication if I feel dizzy."
B. "I should take this medication with food to avoid stomach upset."
C. "I will monitor my blood pressure and pulse daily."
D. "This medication will increase my heart rate."
Answer: C. "I will monitor my blood pressure and pulse daily."
Rationale: Carvedilol is a beta-blocker that decreases heart rate and
blood pressure. Patients should monitor these parameters daily and
report significant changes. The medication should not be stopped
abruptly due to rebound tachycardia and hypertension. It can be taken
without regard to meals.
6. A patient on warfarin (Coumadin) has an INR of 5.8. Which
medication should the nurse anticipate administering?
A. Protamine sulfate
B. Vitamin K
C. Aminocaproic acid
D. Desmopressin
Answer: B. Vitamin K
, Rationale: Vitamin K is the antidote for warfarin. An INR of 5.8 indicates
excessive anticoagulation and increased bleeding risk. Protamine sulfate
is the antidote for heparin. The therapeutic INR range for most
indications is 2.0-3.0.
7. A patient is prescribed an ACE inhibitor for heart failure. Which
adverse effect should the nurse teach the patient to report
immediately?
A. Dry cough
B. Angioedema
C. Hyperkalemia
D. Hypotension
Answer: B. Angioedema
Rationale: Angioedema is a rare but life-threatening adverse effect of
ACE inhibitors characterized by swelling of the face, lips, tongue, and
airways. This requires immediate medical attention. While dry cough,
hyperkalemia, and hypotension are also adverse effects, they are not
immediately life-threatening.
8. Which medication is classified as an angiotensin II receptor blocker
(ARB)?
A. Lisinopril
B. Losartan
C. Enalapril
D. Captopril