1. 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.
2. 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.
3. A client on sildenafil experiences chest pain during
intercourse. What is the nurse’s next action?
A. Administer nitroglycerin
B. Encourage rest and fluids
C. Call emergency services
D. Administer aspirin
Answer: C
Rationale: Sildenafil + nitrates can cause life-threatening
hypotension. Do not give nitro—call 911.
4. A client is started on lorazepam for anxiety. Which
teaching
point is essential?
A. “Avoid grapefruit juice.”
B. “Take with NSAIDs.”
C. “Do not stop abruptly.”
D. “It may take weeks to work.”
Answer: C
Rationale: Benzodiazepines must be tapered to prevent
withdrawal symptoms and seizures.
5. A nurse is caring for a client on glipizide. Which
statement
indicates understanding?
, A. “I can skip meals if I’m not hungry.”
B. “This medication will not cause low blood sugar.”
C. “I will avoid alcohol while taking this.”
D. “I can take this with grapefruit juice.”
Answer: C
Rationale: Alcohol with glipizide increases the risk of
hypoglycemia and a disulfiram-like reaction.
6. A client is prescribed loperamide. Which condition is a
contraindication?
A. IBS
B. Infectious diarrhea
C. Traveler’s diarrhea
D. Post-antibiotic diarrhea
Answer: B
Rationale: Do not use antidiarrheals in infectious diarrhea,
as it
may retain toxins in the bowel.
7. 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.
8. A nurse is educating a client on atorvastatin. What side
effect
should the client report immediately?
A. Headache
B. Muscle pain
C. Drowsiness
D. Constipation
Answer: B
Rationale: Myopathy can occur with statins and may
progress to
rhabdomyolysis. Report muscle pain immediately.
9. A client taking carbidopa/levodopa reports facial
twitching
and eye spasms. What should the nurse do?
A. Reassure the client this is expected
B. Hold the dose and notify the provider
C. Administer diphenhydramine
D. Document and continue monitoring
Answer: B
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.
2. 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.
3. A client on sildenafil experiences chest pain during
intercourse. What is the nurse’s next action?
A. Administer nitroglycerin
B. Encourage rest and fluids
C. Call emergency services
D. Administer aspirin
Answer: C
Rationale: Sildenafil + nitrates can cause life-threatening
hypotension. Do not give nitro—call 911.
4. A client is started on lorazepam for anxiety. Which
teaching
point is essential?
A. “Avoid grapefruit juice.”
B. “Take with NSAIDs.”
C. “Do not stop abruptly.”
D. “It may take weeks to work.”
Answer: C
Rationale: Benzodiazepines must be tapered to prevent
withdrawal symptoms and seizures.
5. A nurse is caring for a client on glipizide. Which
statement
indicates understanding?
, A. “I can skip meals if I’m not hungry.”
B. “This medication will not cause low blood sugar.”
C. “I will avoid alcohol while taking this.”
D. “I can take this with grapefruit juice.”
Answer: C
Rationale: Alcohol with glipizide increases the risk of
hypoglycemia and a disulfiram-like reaction.
6. A client is prescribed loperamide. Which condition is a
contraindication?
A. IBS
B. Infectious diarrhea
C. Traveler’s diarrhea
D. Post-antibiotic diarrhea
Answer: B
Rationale: Do not use antidiarrheals in infectious diarrhea,
as it
may retain toxins in the bowel.
7. 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.
8. A nurse is educating a client on atorvastatin. What side
effect
should the client report immediately?
A. Headache
B. Muscle pain
C. Drowsiness
D. Constipation
Answer: B
Rationale: Myopathy can occur with statins and may
progress to
rhabdomyolysis. Report muscle pain immediately.
9. A client taking carbidopa/levodopa reports facial
twitching
and eye spasms. What should the nurse do?
A. Reassure the client this is expected
B. Hold the dose and notify the provider
C. Administer diphenhydramine
D. Document and continue monitoring
Answer: B
