NUR 100/NUR100 Exam 4 V3 | Pharmacology Q&A
with Rationale | Fortis College
1. A nurse is preparing to administer digoxin to a patient with heart failure. Which
assessment finding would require the nurse to withhold the medication?
A. Blood pressure of 140/90 mmHg
B. Apical pulse of 52 beats per minute
C. Respiratory rate of 18 breaths per minute
D. Serum potassium level of 4.5 mEq/L
Correct Answer: B
Explanation: Digoxin is a cardiac glycoside that increases the force of contraction but
slows the heart rate. The nurse must assess the apical pulse for a full minute before
administration and withhold the dose if it is less than 60 beats per minute. This action
prevents further bradycardia and potential digoxin toxicity in the adult patient.
2. A patient is receiving morphine sulfate via IV push for postoperative pain. Which of the
following findings is the nurse’s priority for intervention?
A. Respiratory rate of 8 breaths per minute
B. Constipation and abdominal distension
C. Nausea and vomiting
D. Urinary retention of 200 mL
,Correct Answer: A
Explanation: Opioid analgesics like morphine can cause significant central nervous system
depression, leading to respiratory failure. A respiratory rate of 8 is dangerously low and
requires immediate intervention with oxygen and potential administration of naloxone.
While constipation and nausea are common side effects, they are not life-threatening
compared to respiratory depression.
3. A nurse is teaching a patient about the side effects of furosemide. Which of the following
instructions should the nurse include?
A. Avoid foods high in potassium like bananas.
B. Change positions slowly to prevent dizziness.
C. Take the medication at bedtime to ensure absorption.
D. Limit fluid intake to less than 1 liter per day.
Correct Answer: B
Explanation: Furosemide is a loop diuretic that can cause orthostatic hypotension due to
rapid fluid loss. Patients should be taught to change positions slowly to minimize the risk of
falls and dizziness. Furthermore, since furosemide is potassium-wasting, patients are
usually encouraged to increase rather than decrease potassium intake.
4. Which laboratory value is most important for a nurse to monitor for a patient receiving
heparin therapy?
A. Prothrombin time (PT)
, B. International Normalized Ratio (INR)
C. Glycosylated hemoglobin (HbA1c)
D. Activated partial thromboplastin time (aPTT)
Correct Answer: D
Explanation: The aPTT is the standard laboratory test used to monitor the effectiveness of
heparin therapy and adjust dosing. PT and INR are typically used to monitor warfarin
therapy rather than heparin. Maintaining the aPTT within the therapeutic range is crucial
to prevent both clots and excessive bleeding.
5. A patient who has been taking warfarin for atrial fibrillation has an INR of 5.5. What
medication should the nurse expect the provider to order?
A. Vitamin K
B. Protamine sulfate
C. Enoxaparin
D. Aspirin
Correct Answer: A
Explanation: Vitamin K is the specific antidote used to reverse the anticoagulant effects of
warfarin when the INR is excessively high. An INR of 5.5 indicates a significant risk for
spontaneous bleeding. Protamine sulfate is the antidote for heparin, not warfarin.
with Rationale | Fortis College
1. A nurse is preparing to administer digoxin to a patient with heart failure. Which
assessment finding would require the nurse to withhold the medication?
A. Blood pressure of 140/90 mmHg
B. Apical pulse of 52 beats per minute
C. Respiratory rate of 18 breaths per minute
D. Serum potassium level of 4.5 mEq/L
Correct Answer: B
Explanation: Digoxin is a cardiac glycoside that increases the force of contraction but
slows the heart rate. The nurse must assess the apical pulse for a full minute before
administration and withhold the dose if it is less than 60 beats per minute. This action
prevents further bradycardia and potential digoxin toxicity in the adult patient.
2. A patient is receiving morphine sulfate via IV push for postoperative pain. Which of the
following findings is the nurse’s priority for intervention?
A. Respiratory rate of 8 breaths per minute
B. Constipation and abdominal distension
C. Nausea and vomiting
D. Urinary retention of 200 mL
,Correct Answer: A
Explanation: Opioid analgesics like morphine can cause significant central nervous system
depression, leading to respiratory failure. A respiratory rate of 8 is dangerously low and
requires immediate intervention with oxygen and potential administration of naloxone.
While constipation and nausea are common side effects, they are not life-threatening
compared to respiratory depression.
3. A nurse is teaching a patient about the side effects of furosemide. Which of the following
instructions should the nurse include?
A. Avoid foods high in potassium like bananas.
B. Change positions slowly to prevent dizziness.
C. Take the medication at bedtime to ensure absorption.
D. Limit fluid intake to less than 1 liter per day.
Correct Answer: B
Explanation: Furosemide is a loop diuretic that can cause orthostatic hypotension due to
rapid fluid loss. Patients should be taught to change positions slowly to minimize the risk of
falls and dizziness. Furthermore, since furosemide is potassium-wasting, patients are
usually encouraged to increase rather than decrease potassium intake.
4. Which laboratory value is most important for a nurse to monitor for a patient receiving
heparin therapy?
A. Prothrombin time (PT)
, B. International Normalized Ratio (INR)
C. Glycosylated hemoglobin (HbA1c)
D. Activated partial thromboplastin time (aPTT)
Correct Answer: D
Explanation: The aPTT is the standard laboratory test used to monitor the effectiveness of
heparin therapy and adjust dosing. PT and INR are typically used to monitor warfarin
therapy rather than heparin. Maintaining the aPTT within the therapeutic range is crucial
to prevent both clots and excessive bleeding.
5. A patient who has been taking warfarin for atrial fibrillation has an INR of 5.5. What
medication should the nurse expect the provider to order?
A. Vitamin K
B. Protamine sulfate
C. Enoxaparin
D. Aspirin
Correct Answer: A
Explanation: Vitamin K is the specific antidote used to reverse the anticoagulant effects of
warfarin when the INR is excessively high. An INR of 5.5 indicates a significant risk for
spontaneous bleeding. Protamine sulfate is the antidote for heparin, not warfarin.
