1. 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.
2. A client is taking diphenhydramine. Which side effect is most
likely?
A. Hypertension
B. Drowsiness
C. Diarrhea
D. Insomnia
Answer: B
Rationale: First-generation antihistamines like diphenhydramine
cause sedation and drowsiness.
3. A nurse is administering digoxin to a client. Which finding
requires immediate action?
A. HR 62 bpm
B. Blurred vision with yellow halos
C. BP 140/88 mmHg
D. Urine output 400 mL in 8 hours
,Answer: B
Rationale: Visual disturbances and halos are signs of digoxin
toxicity, especially when paired with bradycardia.
4. A client on sertraline reports increased restlessness and
confusion. What should the nurse suspect?
A. Extrapyramidal symptoms
B. Lithium toxicity
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Answer: C
Rationale: Serotonin syndrome includes agitation, confusion,
tachycardia, and hyperreflexia.
5. A client with COPD is on prednisone. Which instruction is
appropriate?
A. Stop taking it once symptoms resolve
B. Take on an empty stomach
C. Report black tarry stools
D. Avoid potassium-rich foods
Answer: C
Rationale: Corticosteroids increase the risk for GI bleeding and
ulcers. Tarry stools may indicate bleeding.
6. A client with myasthenia gravis is prescribed neostigmine.
Which finding indicates underdosing?
A. Bradycardia
B. Muscle weakness
, C. Diarrhea
D. Excessive salivation
Answer: B
Rationale: Muscle weakness could indicate myasthenic crisis,
requiring dosage adjustment.
7. A client taking haloperidol develops a high fever and muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
C. Tardive dyskinesia
D. Extrapyramidal symptoms (EPS)
Answer: B
Rationale: NMS is a rare but fatal reaction to antipsychotics.
Requires immediate intervention.
8. A client with chronic constipation uses magnesium citrate daily.
What risk should the nurse discuss?
A. Hypertension
B. Hypernatremia
C. Electrolyte imbalance
D. Dehydration
Answer: C
Rationale: Chronic laxative use, especially osmotic types like
magnesium citrate, causes fluid and electrolyte imbalances.
9. A client taking warfarin has an INR of 4.2. Which action should
the nurse take?
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.
2. A client is taking diphenhydramine. Which side effect is most
likely?
A. Hypertension
B. Drowsiness
C. Diarrhea
D. Insomnia
Answer: B
Rationale: First-generation antihistamines like diphenhydramine
cause sedation and drowsiness.
3. A nurse is administering digoxin to a client. Which finding
requires immediate action?
A. HR 62 bpm
B. Blurred vision with yellow halos
C. BP 140/88 mmHg
D. Urine output 400 mL in 8 hours
,Answer: B
Rationale: Visual disturbances and halos are signs of digoxin
toxicity, especially when paired with bradycardia.
4. A client on sertraline reports increased restlessness and
confusion. What should the nurse suspect?
A. Extrapyramidal symptoms
B. Lithium toxicity
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Answer: C
Rationale: Serotonin syndrome includes agitation, confusion,
tachycardia, and hyperreflexia.
5. A client with COPD is on prednisone. Which instruction is
appropriate?
A. Stop taking it once symptoms resolve
B. Take on an empty stomach
C. Report black tarry stools
D. Avoid potassium-rich foods
Answer: C
Rationale: Corticosteroids increase the risk for GI bleeding and
ulcers. Tarry stools may indicate bleeding.
6. A client with myasthenia gravis is prescribed neostigmine.
Which finding indicates underdosing?
A. Bradycardia
B. Muscle weakness
, C. Diarrhea
D. Excessive salivation
Answer: B
Rationale: Muscle weakness could indicate myasthenic crisis,
requiring dosage adjustment.
7. A client taking haloperidol develops a high fever and muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
C. Tardive dyskinesia
D. Extrapyramidal symptoms (EPS)
Answer: B
Rationale: NMS is a rare but fatal reaction to antipsychotics.
Requires immediate intervention.
8. A client with chronic constipation uses magnesium citrate daily.
What risk should the nurse discuss?
A. Hypertension
B. Hypernatremia
C. Electrolyte imbalance
D. Dehydration
Answer: C
Rationale: Chronic laxative use, especially osmotic types like
magnesium citrate, causes fluid and electrolyte imbalances.
9. A client taking warfarin has an INR of 4.2. Which action should
the nurse take?
