1
1. A nurse is assessing 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: b. Distended neck veins
2. A nurse is caring for a client who has hyponatremia and is receiving an
infusion of a prescribed hypertonic solution. Which of the following findings
should indicate to the nurse that the treatment is effective?
a. Absent Chvostek's sign
b. Improved cognition
c. Decreased vomiting
d. Cardiac arrhythmias absent: b. Improved cognition
3. A nurse is teaching a client who has a new prescription for a nitroglycerin
transdermal patch. Which of the following instructions should the nurse in-
clude?
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.": d. "Remove the patch prior to going
to bed."
4. A nurse is reviewing he laboratory results of a client who has a prescription
for sodium polystyrene sulfonate (Kayexalate) every 6 hr. which of the follow-
ing 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: d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassi-
um level greater than 5.0 mEq/L) increases the client risk for fatal cardiac dysrhyth-
mias. Kayexalate is used to decrease the serum potassium level so the PN should
monitor the client's serum potassium level
5. 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
amurimi
a
,2
d. The client's liver function test results are within the expected reference
range: a. The client has a negative sputum culture
6. A client is caring for a client who develops an anaphylactic reaction to IV
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: d. Administer epinephrine IM
7. 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: a. St. John's Wort
8. 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
when administering lisinopril?
a. Bradycardia
b. Hypokalemia
c. Tinnitus
d. Hypotension: d. Hypotension
9. A nurse is assessing a client who is receiving heparin IV continuous IV. The
client has an PPT of 90 seconds. They should monitor the client for which of
the following changes in their vital signs?
a. Decreased temperature
b. Increased pulse rate
c. Decreased respiratory rate
d. Increased blood pressure: d. Increased blood pressure
10. 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: b. The nurse who identifies the error
amurimi
a
,3
11. A nurse is planning care for a client who is receiving morphine via contin-
uous epidural infusion. The nurse should monitor the client for which of the
following?
a. Pruritus
b. Cough
c. Tachypnea
d. Gastric bleeding: a. Pruritus - Sign of allergic reaction to morphine
12. A nurse is preparing to administer digoxin orally to a client. Identify the
sequence of steps the nurse should take. (Move the steps into the box on the
right placing them in the order of performance. Use all the steps.): a. Obtain
the client's apical heart rate
b. Remove the medication from the dispensing system
c. Open the medication package
d. Compare the client's wristband to the medication administration record
e. Document administration of the medication
13. A nurse is reviewing the medical record of an adult client who has a fever
and a prescription for acetaminophen. Which of the following findings should
the nurse identify as a contraindication for receiving this medication?
a. Alcohol use disorder
b. Chronic kidney disease
c. Hepatitis B vaccine within the last week
d. Diabetes mellitus: a. Alcohol use disorder
b. Chronic kidney disease
14. A home health nurse is visiting a client who has heart failure and a
prescription for furosemide. The nurse identifies that the client has gained 2.5
kg (5 lb.) since the last visit 2 days ago. Which of the following actions should
the nurse take first?
a. Encourage the client to dangle the legs while sitting in a chair
b. Teach the client about foods low in sodium
c. Determine medication adherence by the client
d. Notify the provider of the client's weight gain: c. Determine medication adher-
ence by the client
15. A nurse is preparing to administer the initial dose of penicillin G IM to a
client. The nurse should monitor for which of the following as an indication of
an allergic reaction following the injection?
a. Urticaria
b. Bradycardia
amurimi
a
1. A nurse is assessing 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: b. Distended neck veins
2. A nurse is caring for a client who has hyponatremia and is receiving an
infusion of a prescribed hypertonic solution. Which of the following findings
should indicate to the nurse that the treatment is effective?
a. Absent Chvostek's sign
b. Improved cognition
c. Decreased vomiting
d. Cardiac arrhythmias absent: b. Improved cognition
3. A nurse is teaching a client who has a new prescription for a nitroglycerin
transdermal patch. Which of the following instructions should the nurse in-
clude?
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.": d. "Remove the patch prior to going
to bed."
4. A nurse is reviewing he laboratory results of a client who has a prescription
for sodium polystyrene sulfonate (Kayexalate) every 6 hr. which of the follow-
ing 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: d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassi-
um level greater than 5.0 mEq/L) increases the client risk for fatal cardiac dysrhyth-
mias. Kayexalate is used to decrease the serum potassium level so the PN should
monitor the client's serum potassium level
5. 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
amurimi
a
,2
d. The client's liver function test results are within the expected reference
range: a. The client has a negative sputum culture
6. A client is caring for a client who develops an anaphylactic reaction to IV
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: d. Administer epinephrine IM
7. 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: a. St. John's Wort
8. 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
when administering lisinopril?
a. Bradycardia
b. Hypokalemia
c. Tinnitus
d. Hypotension: d. Hypotension
9. A nurse is assessing a client who is receiving heparin IV continuous IV. The
client has an PPT of 90 seconds. They should monitor the client for which of
the following changes in their vital signs?
a. Decreased temperature
b. Increased pulse rate
c. Decreased respiratory rate
d. Increased blood pressure: d. Increased blood pressure
10. 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: b. The nurse who identifies the error
amurimi
a
,3
11. A nurse is planning care for a client who is receiving morphine via contin-
uous epidural infusion. The nurse should monitor the client for which of the
following?
a. Pruritus
b. Cough
c. Tachypnea
d. Gastric bleeding: a. Pruritus - Sign of allergic reaction to morphine
12. A nurse is preparing to administer digoxin orally to a client. Identify the
sequence of steps the nurse should take. (Move the steps into the box on the
right placing them in the order of performance. Use all the steps.): a. Obtain
the client's apical heart rate
b. Remove the medication from the dispensing system
c. Open the medication package
d. Compare the client's wristband to the medication administration record
e. Document administration of the medication
13. A nurse is reviewing the medical record of an adult client who has a fever
and a prescription for acetaminophen. Which of the following findings should
the nurse identify as a contraindication for receiving this medication?
a. Alcohol use disorder
b. Chronic kidney disease
c. Hepatitis B vaccine within the last week
d. Diabetes mellitus: a. Alcohol use disorder
b. Chronic kidney disease
14. A home health nurse is visiting a client who has heart failure and a
prescription for furosemide. The nurse identifies that the client has gained 2.5
kg (5 lb.) since the last visit 2 days ago. Which of the following actions should
the nurse take first?
a. Encourage the client to dangle the legs while sitting in a chair
b. Teach the client about foods low in sodium
c. Determine medication adherence by the client
d. Notify the provider of the client's weight gain: c. Determine medication adher-
ence by the client
15. A nurse is preparing to administer the initial dose of penicillin G IM to a
client. The nurse should monitor for which of the following as an indication of
an allergic reaction following the injection?
a. Urticaria
b. Bradycardia
amurimi
a
