1. Which statement indicates proper understanding of
enoxaparin (Lovenox) administration?
A. “I will inject it into my thigh muscle.”
B. “I will rub the site after injection.”
C. “I will inject it into my belly fat.”
D. “I must monitor my INR daily.”
Answer: C
Rationale: Enoxaparin is given subcutaneously, preferably
in the
abdomen, and INR monitoring is not required.
2. 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.
3. 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.
4. 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.
5. A client uses sublingual nitroglycerin. Which instruction
is
, correct?
A. Swallow the pill with water
B. Take up to 3 doses, 5 minutes apart
C. Store it in a warm area
D. Use it once weekly
Answer: B
Rationale: For chest pain, take 1 tablet every 5 minutes, up
to 3
doses, and call 911 if no relief after the first.
6. 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.
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 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 isoniazid (INH) for tuberculosis develops
numbness and tingling in their hands and feet. What should
the
nurse anticipate?
enoxaparin (Lovenox) administration?
A. “I will inject it into my thigh muscle.”
B. “I will rub the site after injection.”
C. “I will inject it into my belly fat.”
D. “I must monitor my INR daily.”
Answer: C
Rationale: Enoxaparin is given subcutaneously, preferably
in the
abdomen, and INR monitoring is not required.
2. 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.
3. 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.
4. 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.
5. A client uses sublingual nitroglycerin. Which instruction
is
, correct?
A. Swallow the pill with water
B. Take up to 3 doses, 5 minutes apart
C. Store it in a warm area
D. Use it once weekly
Answer: B
Rationale: For chest pain, take 1 tablet every 5 minutes, up
to 3
doses, and call 911 if no relief after the first.
6. 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.
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 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 isoniazid (INH) for tuberculosis develops
numbness and tingling in their hands and feet. What should
the
nurse anticipate?
