Questions and Answers |Rationales
1. A nurse is monitoring a client who is receiving a digoxin infusion. Which of the
following findings should the nurse identify as a manifestation of digoxin
toxicity?
A. Yellow-tinged vision
B. Muscle weakness
C. Tinnitus
D. Dry cough
Answer: A
Rationale: Visual disturbances, such as yellow or green halos and blurred vision, are
classic signs of digoxin toxicity.
2. A nurse is teaching a client who has a new prescription for ferrous sulfate.
Which of the following instructions should the nurse include?
A. Take the medication with an antacid.
B. Take the medication with milk.
C. Expect stools to turn a bright red color.
D. Drink the liquid form through a straw.
Answer: D
Rationale: Liquid iron preparations can stain teeth; drinking through a straw helps
prevent this. It should be taken with Vitamin C, not antacids or milk, to increase absorption.
,3. A nurse is providing teaching to a client who has a new prescription for
furosemide. Which of the following foods should the nurse recommend the
client consume?
A. Processed meats
B. White bread
C. Cheddar cheese
D. Bananas
Answer: D
Rationale: Furosemide is a loop diuretic that causes potassium loss. Bananas are high in
potassium and help prevent hypokalemia.
4. A nurse is preparing to administer heparin subcutaneously to a client. Which
of the following actions should the nurse plan to take?
A. Aspirate before injecting the medication.
B. Massage the site after the injection.
C. Administer the injection in the abdomen.
D. Use a 22-gauge needle for the injection.
Answer: C
Rationale: Subcutaneous heparin should be administered in the abdomen, at least 2 inches
from the umbilicus. Aspiration and massage are contraindicated.
5. A nurse is caring for a client who is taking warfarin. Which of the following
laboratory values should the nurse monitor?
A. aPTT
B. INR
C. BUN
D. Hemoglobin
Answer: B
, Rationale: INR (International Normalized Ratio) and PT (Prothrombin Time) are used to
monitor the effectiveness of warfarin therapy.
6. A nurse is caring for a client who has a prescription for albuterol. The nurse
should monitor for which of the following adverse effects?
A. Tachycardia
B. Bradycardia
C. Drowsiness
D. Hypoglycemia
Answer: A
Rationale: Albuterol is a sympathomimetic bronchodilator that can cause tachycardia,
tremors, and nervousness.
7. A nurse is reviewing the medication record of a client who is taking lithium
carbonate. Which of the following medications should the nurse identify as a
risk for lithium toxicity?
A. Acetaminophen
B. Aspirin
C. Ibuprofen
D. Vitamin C
Answer: C
Rationale: NSAIDs like ibuprofen increase renal reabsorption of lithium, leading to toxic
levels. Acetaminophen is generally safer.