Actual Exam Questions With Complete
Solutions
A nurse is monitoring a client who has just returned to the unit following surgery. The
client received an initial dose of morphine 5 mg IV bolus for pain relief. Which of the
following adverse effects should the nurse report immediately to the provider? -
CORRECT ANSWER-Respiratory rate 11/min
When using the airway, breathing, circulation approach to client care, the priority finding
is a respiratory rate of 11/min indicating respiratory depression.
A nurse is reinforcing teaching with a client who is prescribed captopril for hypertension.
Which of the following side effects should the nurse instruct the client to report to the
provider immediately? - CORRECT ANSWER-Sore throat
The greatest risk to the client is infection related to neutropenia. Unexplained fever, sore
throat, and fatigue can indicate an infection and should be immediately reported to the
provider.
A nurse is reinforcing teaching with a client who has a new prescription for
spironolactone for hypertension. Which of the following instructions should the nurse
include in the teaching? - CORRECT ANSWER-Restrict foods high in potassium.
Spironolactone is a potassium-sparing diuretic, which can cause hyperkalemia.
Therefore, the client should restrict foods that are high in potassium.
A nurse is reinforcing teaching with a client about the adverse effects of simvastatin. For
which of the following adverse effects should the nurse instruct the client to monitor? -
CORRECT ANSWER-Muscle pain
The nurse should instruct the client to notify the provider if muscle pain or tenderness
develops, because this could indicate rhabdomyolysis.
A nurse is performing the third check before administering hydromorphone to a client.
After opening the unit-dose packet, the client tells the nurse he does not want to take
the medication now. Which of the following actions should the nurse take? - CORRECT
ANSWER-Dispose of the medication with a second nurse as a witness.
, The nurse must have a witness when disposing of a controlled substance.
A nurse is caring for a client who is prescribed an IM injection of penicillin G benzathine.
The client asks why the injection must be given IM instead of through his IV line. Which
of the following is the correct response by the nurse? - CORRECT ANSWER-"Your
medication can't be given IV because it is not water-soluble."
Medications cannot be administered IV if they are not water-soluble.
A nurse is assisting with the care of a client who is in preterm labor and is receiving
magnesium sulfate by continuous IV infusion. Which of the following findings indicats
magnesium toxicity? - CORRECT ANSWER-Hyporeflexia
Magnesium sulfate depresses neuromuscular activity, leading to muscle weakness and
paralysis. Therefore, hyporeflexia can indicate magnesium toxicity.
A nurse is reinforcing teaching with a client who is prescribed a scopolamine patch for
motion sickness. Which of the following client statements indicates an understanding of
the teaching? - CORRECT ANSWER-"I should place the patch behind my ear."
The client should place the scopolamine patch behind the ear.
A nurse is monitoring a client who is receiving IV amphotericin B. Which of the following
findings indicates an adverse reaction to this medication? - CORRECT ANSWER-
Vertigo
Ototoxicity is an adverse effect of amphotericin B. Manifestations of ototoxicity include
vertigo, tinnitus, and hearing loss.
A nurse is reinforcing teaching with a client who is using phenylephrine nasal spray
three times daily and reports rebound congestion. Which of the following instructions
should the nurse include to reduce the effects of rebound congestion? - CORRECT
ANSWER-"Discontinue use in the left nostril, then in the right nostril."
Discontinuing the drug one nostril at a time can overcome rebound congestion.
A nurse is caring for a client who has just received a prescription for tolbutamide to treat
diabetes mellitus. The nurse should question the prescription if the client reports which
of the following medication allergies? - CORRECT
ANSWER-Trimethoprim/sulfamethoxazole