1. A client on clozapine reports fever and sore throat. What is the
priority action?
A. Reassure and monitor
B. Administer antipyretics
C. Check WBC count
D. Suggest lozenges
Answer: C
Rationale: Clozapine can cause agranulocytosis. A fever + sore
throat may signal low WBC—check labs.
2. A client started on fluoxetine 5 days ago reports increased
energy and planning their funeral. What should the nurse do?
A. Encourage journaling
B. Monitor sleep
C. Notify the provider immediately
D. Provide distraction techniques
Answer: C
Rationale: Increased energy + suicidal ideation early in SSRI
therapy is dangerous and should be reported.
3. A client is using a scopolamine patch for motion sickness. What
side effect should the nurse monitor?
A. Diarrhea
B. Blurred vision and dry mouth
C. Rash
D. Hearing loss
,Answer: B
Rationale: Scopolamine has anticholinergic effects like dry mouth,
blurred vision, and urinary retention.
4. A client taking phenytoin shows swollen, bleeding gums. What
should the nurse recommend?
A. Discontinue the drug
B. Increase fluid intake
C. Practice good oral hygiene
D. Reduce dietary sugar
Answer: C
Rationale: Gingival hyperplasia is a known side effect. Encourage
oral care, not discontinuation.
5. A nurse monitors a client taking lamotrigine. What adverse
effect should prompt discontinuation?
A. Rash
B. Constipation
C. Nausea
D. Drowsiness
Answer: A
Rationale: Lamotrigine can cause a life-threatening rash (e.g.,
Stevens-Johnson syndrome). Report immediately.
6. A client is receiving morphine IV post-op. Which finding is the
priority?
A. Nausea
B. Respiratory rate of 8/min
, C. Itching
D. Sedation score of 2
Answer: B
Rationale: Respiratory depression (<12/min) is the most life-
threatening side effect of opioids.
7. A post-op client is given ondansetron. Which is an expected
outcome?
A. Decreased heart rate
B. Absence of nausea
C. Increased bowel sounds
D. Sedation
Answer: B
Rationale: Ondansetron is a serotonin antagonist used to prevent
or treat nausea and vomiting.
8. A client taking omeprazole asks why it is prescribed. Which
response is correct?
A. "It coats the lining of the stomach."
B. "It neutralizes gastric acid."
C. "It blocks acid production."
D. "It stimulates protective mucus production."
Answer: C
Rationale: Omeprazole is a proton pump inhibitor (PPI) that
blocks gastric acid secretion.
9. A nurse gives regular insulin subcutaneously at 0700. At what
time should the nurse monitor for signs of hypoglycemia?
priority action?
A. Reassure and monitor
B. Administer antipyretics
C. Check WBC count
D. Suggest lozenges
Answer: C
Rationale: Clozapine can cause agranulocytosis. A fever + sore
throat may signal low WBC—check labs.
2. A client started on fluoxetine 5 days ago reports increased
energy and planning their funeral. What should the nurse do?
A. Encourage journaling
B. Monitor sleep
C. Notify the provider immediately
D. Provide distraction techniques
Answer: C
Rationale: Increased energy + suicidal ideation early in SSRI
therapy is dangerous and should be reported.
3. A client is using a scopolamine patch for motion sickness. What
side effect should the nurse monitor?
A. Diarrhea
B. Blurred vision and dry mouth
C. Rash
D. Hearing loss
,Answer: B
Rationale: Scopolamine has anticholinergic effects like dry mouth,
blurred vision, and urinary retention.
4. A client taking phenytoin shows swollen, bleeding gums. What
should the nurse recommend?
A. Discontinue the drug
B. Increase fluid intake
C. Practice good oral hygiene
D. Reduce dietary sugar
Answer: C
Rationale: Gingival hyperplasia is a known side effect. Encourage
oral care, not discontinuation.
5. A nurse monitors a client taking lamotrigine. What adverse
effect should prompt discontinuation?
A. Rash
B. Constipation
C. Nausea
D. Drowsiness
Answer: A
Rationale: Lamotrigine can cause a life-threatening rash (e.g.,
Stevens-Johnson syndrome). Report immediately.
6. A client is receiving morphine IV post-op. Which finding is the
priority?
A. Nausea
B. Respiratory rate of 8/min
, C. Itching
D. Sedation score of 2
Answer: B
Rationale: Respiratory depression (<12/min) is the most life-
threatening side effect of opioids.
7. A post-op client is given ondansetron. Which is an expected
outcome?
A. Decreased heart rate
B. Absence of nausea
C. Increased bowel sounds
D. Sedation
Answer: B
Rationale: Ondansetron is a serotonin antagonist used to prevent
or treat nausea and vomiting.
8. A client taking omeprazole asks why it is prescribed. Which
response is correct?
A. "It coats the lining of the stomach."
B. "It neutralizes gastric acid."
C. "It blocks acid production."
D. "It stimulates protective mucus production."
Answer: C
Rationale: Omeprazole is a proton pump inhibitor (PPI) that
blocks gastric acid secretion.
9. A nurse gives regular insulin subcutaneously at 0700. At what
time should the nurse monitor for signs of hypoglycemia?
