1. A client with herpes simplex is prescribed acyclovir.
What is the
most important teaching?
A. "Take on an empty stomach."
B. "Drink plenty of fluids."
C. "Discontinue when symptoms improve."
D. "Expect yellowing of the eyes."
Answer: B
Rationale: Acyclovir can cause nephrotoxicity. Hydration is
essential to reduce the risk.
2. 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.
3. A nurse is teaching a client about hydroxychloroquine
for
lupus. What adverse effect should be reported immediately?
A. Dizziness
B. Blurred vision
C. Dry mouth
D. Rash
Answer: B
Rationale: Retinal damage is a serious side effect. Clients
need
regular eye exams.
4. A client with asthma uses albuterol PRN. Which
statement
shows proper understanding?
A. “I use this every morning and night.”
B. “I use this when I’m having shortness of breath.”
C. “I use it with my steroid inhaler at the same time.”
D. “I use this even if I’m not having symptoms.”
Answer: B
Rationale: Albuterol is a rescue inhaler used during asthma
attacks
or acute symptoms.
5. 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.
6. A client taking warfarin has an INR of 4.2. Which action
should
the nurse take?
A. Administer the next dose of warfarin
B. Hold the dose and notify the provider
C. Give vitamin K IV immediately
D. Prepare for platelet transfusion
Answer: B
Rationale: An INR >3.0 indicates increased bleeding risk.
The
nurse should hold the medication and notify the provider.
7. 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.
8. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
D. Blood glucose
Answer: B
Rationale: Metoprolol can cause bradycardia. Always check
HR
before administering.
9. A client is taking diphenhydramine. Which side effect is
most
likely?
A. Hypertension
B. Drowsiness
C. Diarrhea
D. Insomnia
What is the
most important teaching?
A. "Take on an empty stomach."
B. "Drink plenty of fluids."
C. "Discontinue when symptoms improve."
D. "Expect yellowing of the eyes."
Answer: B
Rationale: Acyclovir can cause nephrotoxicity. Hydration is
essential to reduce the risk.
2. 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.
3. A nurse is teaching a client about hydroxychloroquine
for
lupus. What adverse effect should be reported immediately?
A. Dizziness
B. Blurred vision
C. Dry mouth
D. Rash
Answer: B
Rationale: Retinal damage is a serious side effect. Clients
need
regular eye exams.
4. A client with asthma uses albuterol PRN. Which
statement
shows proper understanding?
A. “I use this every morning and night.”
B. “I use this when I’m having shortness of breath.”
C. “I use it with my steroid inhaler at the same time.”
D. “I use this even if I’m not having symptoms.”
Answer: B
Rationale: Albuterol is a rescue inhaler used during asthma
attacks
or acute symptoms.
5. 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.
6. A client taking warfarin has an INR of 4.2. Which action
should
the nurse take?
A. Administer the next dose of warfarin
B. Hold the dose and notify the provider
C. Give vitamin K IV immediately
D. Prepare for platelet transfusion
Answer: B
Rationale: An INR >3.0 indicates increased bleeding risk.
The
nurse should hold the medication and notify the provider.
7. 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.
8. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
D. Blood glucose
Answer: B
Rationale: Metoprolol can cause bradycardia. Always check
HR
before administering.
9. A client is taking diphenhydramine. Which side effect is
most
likely?
A. Hypertension
B. Drowsiness
C. Diarrhea
D. Insomnia
