1. A nurse is caring for a client prescribed lisinopril. Which lab
result should the nurse report to the provider?
A. Sodium 138 mEq/L
B. Potassium 5.8 mEq/L
C. Hemoglobin 14 g/dL
D. BUN 18 mg/dL
Answer: B
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia. A
potassium level of 5.8 is elevated and should be reported.
2. A nurse gives regular insulin subcutaneously at 0700. At what
time should the nurse monitor for signs of hypoglycemia?
A. 0715
B. 0800
C. 0930
D. 1200
Answer: C
Rationale: Regular insulin peaks in 2–4 hours. Hypoglycemia is
most likely around 0930–1100.
3. A client taking isoniazid (INH) for tuberculosis develops
numbness and tingling in their hands and feet. What should the
nurse anticipate?
A. The need for increased calcium
B. Administration of pyridoxine (vitamin B6)
C. Discontinuation of therapy
D. Addition of prednisone
Answer: B
Rationale: Isoniazid can cause peripheral neuropathy, often
prevented or treated with vitamin B6.
,4. 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.
5. 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.
6. 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.
7. A nurse teaches a client taking cyclobenzaprine. Which
statement indicates understanding?
A. “I will take this long-term.”
, B. “I can drink alcohol in moderation.”
C. “I should avoid driving until I know how it affects me.”
D. “It will help my heart condition.”
Answer: C
Rationale: Cyclobenzaprine causes drowsiness. Clients should
avoid driving or alcohol initially.
8. A child prescribed methylphenidate for ADHD should be
monitored for which effect?
A. Drowsiness
B. Increased appetite
C. Weight loss and insomnia
D. Bradycardia
Answer: C
Rationale: Stimulants like methylphenidate commonly cause
decreased appetite, insomnia, and weight loss.
9. 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.
10. A nurse monitors a client taking lamotrigine. What adverse
effect should prompt discontinuation?
A. Rash
B. Constipation
C. Nausea
D. Drowsiness
result should the nurse report to the provider?
A. Sodium 138 mEq/L
B. Potassium 5.8 mEq/L
C. Hemoglobin 14 g/dL
D. BUN 18 mg/dL
Answer: B
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia. A
potassium level of 5.8 is elevated and should be reported.
2. A nurse gives regular insulin subcutaneously at 0700. At what
time should the nurse monitor for signs of hypoglycemia?
A. 0715
B. 0800
C. 0930
D. 1200
Answer: C
Rationale: Regular insulin peaks in 2–4 hours. Hypoglycemia is
most likely around 0930–1100.
3. A client taking isoniazid (INH) for tuberculosis develops
numbness and tingling in their hands and feet. What should the
nurse anticipate?
A. The need for increased calcium
B. Administration of pyridoxine (vitamin B6)
C. Discontinuation of therapy
D. Addition of prednisone
Answer: B
Rationale: Isoniazid can cause peripheral neuropathy, often
prevented or treated with vitamin B6.
,4. 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.
5. 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.
6. 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.
7. A nurse teaches a client taking cyclobenzaprine. Which
statement indicates understanding?
A. “I will take this long-term.”
, B. “I can drink alcohol in moderation.”
C. “I should avoid driving until I know how it affects me.”
D. “It will help my heart condition.”
Answer: C
Rationale: Cyclobenzaprine causes drowsiness. Clients should
avoid driving or alcohol initially.
8. A child prescribed methylphenidate for ADHD should be
monitored for which effect?
A. Drowsiness
B. Increased appetite
C. Weight loss and insomnia
D. Bradycardia
Answer: C
Rationale: Stimulants like methylphenidate commonly cause
decreased appetite, insomnia, and weight loss.
9. 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.
10. A nurse monitors a client taking lamotrigine. What adverse
effect should prompt discontinuation?
A. Rash
B. Constipation
C. Nausea
D. Drowsiness
