COMPLETE QUESTIONS WITH 100% CORRECT ANSWERS
1. A nurse is preparing to administer a subcutaneous injection of
heparin to a client. Which action should the nurse take?
A. Aspirate before injecting to check for blood return
B. Massage the site after injection to promote absorption
C. Administer the injection in the abdomen at least 2 inches from the
umbilicus
D. Use a 22-gauge needle for administration
Answer: C. Administer the injection in the abdomen at least 2 inches
from the umbilicus
Rationale: Heparin is administered subcutaneously in the abdomen, at
least 2 inches from the umbilicus, to ensure proper absorption and
avoid bruising. Aspiration is not recommended for subcutaneous
heparin injections as it can cause tissue damage. Massaging the site is
contraindicated as it can cause bruising or hematoma formation. A
smaller gauge needle (25-27 gauge) is typically used for subcutaneous
injections .
2. A client prescribed digoxin has an apical pulse of 52 beats/min.
What action should the nurse take first?
A. Administer the medication as prescribed
B. Hold the medication and notify the healthcare provider
,C. Administer half the prescribed dose
D. Recheck the pulse in 30 minutes
Answer: B. Hold the medication and notify the healthcare provider
Rationale: Digoxin should be held if the apical pulse is below 60
beats/min in adults. The nurse should withhold the medication and
contact the provider for further instructions. Administering digoxin with
bradycardia increases the risk of toxicity and severe cardiac
complications .
3. A nurse is teaching a client about warfarin therapy. Which
statement by the client indicates a need for further teaching?
A. "I will avoid eating large amounts of leafy green vegetables"
B. "I will take ibuprofen for my headaches"
C. "I will have my INR checked regularly"
D. "I will report any unusual bleeding to my provider"
Answer: B. "I will take ibuprofen for my headaches"
Rationale: Ibuprofen and other NSAIDs increase the risk of bleeding
when taken with warfarin. Clients should avoid NSAIDs and use
acetaminophen for pain relief unless otherwise directed by their
provider. The other statements demonstrate appropriate understanding
of warfarin therapy .
4. A client is prescribed furosemide for heart failure. Which laboratory
value should the nurse monitor most closely?
,A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that causes potassium
excretion, leading to hypokalemia. The nurse should monitor serum
potassium levels closely and encourage potassium-rich foods.
Hypokalemia can increase the risk of digoxin toxicity and cardiac
arrhythmias .
5. A nurse is administering morphine sulfate to a client for severe
pain. Which adverse effect should the nurse monitor for?
A. Hypertension
B. Tachypnea
C. Urinary retention
D. Hyperactive bowel sounds
Answer: C. Urinary retention
Rationale: Morphine can cause urinary retention due to increased
bladder sphincter tone and decreased detrusor muscle tone. Other
common adverse effects include respiratory depression, constipation,
nausea, and sedation. Hypertension and tachypnea are not typical
adverse effects of morphine .
, 6. A client is prescribed levothyroxine for hypothyroidism. When
should the nurse instruct the client to take this medication?
A. With food to prevent gastric upset
B. At bedtime with a snack
C. On an empty stomach in the morning
D. With a glass of milk
Answer: C. On an empty stomach in the morning
Rationale: Levothyroxine should be taken on an empty stomach, 30-60
minutes before breakfast, to maximize absorption. Food, calcium
supplements, iron supplements, and certain medications can interfere
with absorption. Taking it at the same time each day maintains
consistent blood levels .
7. A nurse is caring for a client receiving gentamicin IV. Which finding
should the nurse report to the provider?
A. Serum creatinine 0.8 mg/dL
B. Tinnitus
C. Urine output 40 mL/hr
D. Temperature 37.2°C
Answer: B. Tinnitus
Rationale: Gentamicin is an aminoglycoside antibiotic that can cause
ototoxicity, manifested as tinnitus or hearing loss. This finding should be
reported immediately. Nephrotoxicity is another concern; normal urine
output should be at least 30 mL/hr, and creatinine of 0.8 mg/dL is
within normal limits .