1. 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.
2. 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.
3. A client prescribed clopidogrel should avoid which over
the
counter medication?
A. Acetaminophen
B. Ibuprofen
C. Famotidine
D. Guaifenesin
,Answer: B
Rationale: NSAIDs like ibuprofen increase bleeding risk
when
combined with antiplatelet agents like clopidogrel.
4. 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.
5. 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.
6. A client taking furosemide reports muscle cramps.
Which lab
value correlates with this symptom?
A. Sodium 142
B. Potassium 2.9
, C. Chloride 101
D. Magnesium 2.0
Answer: B
Rationale: Furosemide can cause hypokalemia, which leads
to
muscle cramps. Normal potassium: 3.5–5.0.
7. 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.
8. 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.
9. A client is taking diphenhydramine. Which side effect is
most
likely?
A. Hypertension
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.
2. 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.
3. A client prescribed clopidogrel should avoid which over
the
counter medication?
A. Acetaminophen
B. Ibuprofen
C. Famotidine
D. Guaifenesin
,Answer: B
Rationale: NSAIDs like ibuprofen increase bleeding risk
when
combined with antiplatelet agents like clopidogrel.
4. 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.
5. 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.
6. A client taking furosemide reports muscle cramps.
Which lab
value correlates with this symptom?
A. Sodium 142
B. Potassium 2.9
, C. Chloride 101
D. Magnesium 2.0
Answer: B
Rationale: Furosemide can cause hypokalemia, which leads
to
muscle cramps. Normal potassium: 3.5–5.0.
7. 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.
8. 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.
9. A client is taking diphenhydramine. Which side effect is
most
likely?
A. Hypertension
