150 practice Q&As with correct answers and
rationales in italics. Pass your retake with
confidence.
A nurse is caring for a client who is receiving intravenous therapy. The nurse should
identify which of the following findings as a manifestation of fluid volume excess?
A. Decreased bowel sounds
B. Distended neck veins
C. Bilateral muscle weakness
D. Thread pulse
Correct Answer: B
Explanation:
Question 2
A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal
patch. Which of the following instructions should the nurse include?
A. "Discontinue the patch if you experience a headache."
B. "Apply a new patch if you have chest pain."
C. "Cover the patch with dry gauze when taking a shower."
D. "Remove the patch prior to going to bed."
Correct Answer: D
Explanation: *
.*
Question 3
A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin.
Which of the following outcomes indicates that the client is adhering to the medication
,regimen?
A. The client has a negative sputum culture
B. The client tests negative for HIV
C. The client has a positive purified protein derivative test
D. The client's liver function test results are within the expected reference range
Correct Answer: A
Explanation:
Question 4
A client develops an anaphylactic reaction to IV medication administration. After
assessing the client's respiratory status and stopping the medication infusion, which of
the following actions should the nurse take next?
A. Replace the infusion with 0.9% sodium chloride
B. Give diphenhydramine IM
C. Elevate the client's legs and feet
D. Administer epinephrine IM
Correct Answer: D
Explanation:
Question 5
A nurse is caring for a client who is taking sertraline and reports a desire to begin taking
supplements. Which of the following supplements should the nurse advise the client to
avoid?
A. St. John's Wort
B. Ginger root
C. Black cohosh
D. Coenzyme Q10
Correct Answer: A
Explanation:
,Question 6
A nurse is reviewing the laboratory results of a client who has a prescription for sodium
polystyrene sulfonate (Kayexalate) every 6 hr. Which of the following should the nurse
report to the provider?
A. Creatinine 0.72 mg/dL
B. Sodium 138 mEq/L
C. Magnesium 2 mEq/L
D. Potassium 5.2 mEq/L
Correct Answer: D
Explanation: *Kayexalate is used to treat hyperkalemia (high potassium). A potassium
level of 5.2 mEq/L is above the expected reference range (typically 3.5-5.0 mEq/L) and
indicates the medication may not be effective or the client's condition is worsening. The
nurse should report this finding immediately due to risk of cardiac dysrhythmias.*
Question 7
A nurse is caring for a client who has heart failure and a new prescription for lisinopril.
For which of the following adverse effects should the nurse monitor?
A. Bradycardia
B. Hypokalemia
C. Tinnitus
D. Hypotension
Correct Answer: D
Explanation: *Lisinopril is an ACE inhibitor that causes vasodilation. The nurse should
monitor for first-dose hypotension, especially within 1-3 hours after administration.
Other adverse effects include hyperkalemia, dry cough, and angioedema.*
Question 8
A nurse is preparing to administer medication to a client and discovers a medication
error. The nurse should recognize that which of the following staff members is
responsible for completing an incident report?
A. The quality improvement committee
B. The nurse who identifies the error
C. The nurse who caused the error
D. The charge nurse
, Correct Answer: C
Explanation:
Question 9
A nurse is caring for a client who has a new prescription for clozapine. Which of the
following statements should the nurse include in the teaching?
A. "Diarrhea is a common adverse effect of this medication."
B. "Ringing in the ears is an expected adverse effect of this medication."
C. "Notify your provider if you develop a fever while taking this medication."
D. "You might experience weight loss while taking this medication."
Correct Answer: C
Explanation:
Question 10
A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which
of the following findings should the nurse identify as an adverse effect of the
medication?
A. Bradycardia
B. Redman syndrome
C. Hypoglycemia
D. Hypotension
Correct Answer: D
Explanation: *IV phenytoin (Dilantin) can cause severe hypotension and bradycardia if
administered too rapidly. The maximum infusion rate is 50 mg/min. Redman syndrome
is associated with vancomycin. Phenytoin does not typically cause hypoglycemia.*
Question 11
A nurse is providing teaching to a client who has a new prescription for sucralfate.
Which of the following actions of sucralfate should the nurse include in the teaching?
A. Decreases stomach acid secretion