1. A nurse is caring for a client who is receiving lisinopril for
hypertension. The nurse should monitor the client for which
of the following adverse effects?
A. Weight loss
B. Hyperkalemia
C. Hypoglycemia
D. Dehydration
Answer: b) Hyperkalemia
Rationale: Lisinopril, an ACE inhibitor, can cause
hyperkalemia due to its effect on aldosterone secretion. The
nurse should monitor potassium levels.
2. A nurse is caring for a client receiving a blood
transfusion. The nurse should monitor the client for which of
the following signs of an allergic reaction?
A. Tachycardia
B. Fever and chills
C. Rash and itching
D. Cyanosis
Answer: c) Rash and itching
Rationale: Rash and itching are common signs of an allergic
reaction to a blood transfusion. The nurse should stop the
transfusion and notify the provider if these symptoms occur.
3. A nurse is caring for a client with tuberculosis who is
prescribed isoniazid. The nurse should instruct the client to
report which of the following symptoms immediately?
A. Nausea and vomiting
B. Yellowing of the skin or eyes
C. Dizziness
,D. Muscle pain
Answer: b) Yellowing of the skin or eyes
Rationale: Yellowing of the skin or eyes (jaundice) can
indicate hepatotoxicity, a serious side effect of isoniazid.
4. A nurse is preparing to administer morphine to a client for
pain management. Which of the following assessments
should the nurse prioritize before administration?
A. Blood glucose level
B. Respiratory rate
C. Liver function tests
D. Kidney function tests
Answer: b) Respiratory rate
Rationale: Opioids like morphine can cause respiratory
depression, so it is crucial to assess the client's respiratory
rate prior to administration.
5. A nurse is caring for a client who is taking
hydrochlorothiazide. The nurse should monitor the client for
which of the following electrolyte imbalances?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hyponatremia
Answer: c) Hypokalemia
Rationale: Hydrochlorothiazide is a thiazide diuretic that
can cause potassium loss, leading to hypokalemia.
6. A nurse is preparing to administer a dose of naloxone to a
client with opioid overdose. Which of the following actions
should the nurse take?
A. Monitor the client for respiratory depression after
, administration.
B. Administer the drug subcutaneously for faster action.
C. Administer naloxone only if the client is unresponsive to
pain stimuli.
D. Monitor for an increased heart rate as a sign of
effectiveness.
Answer: a) Monitor the client for respiratory depression
after administration.
Rationale: Naloxone is an opioid antagonist used to reverse
opioid toxicity. After administration, the nurse should
monitor the client for signs of respiratory depression and
the need for additional doses.
7. A client is prescribed warfarin. The nurse should instruct
the client to avoid which of the following foods?
A. Bananas
B. Leafy green vegetables
C. Tomatoes
D. Potatoes
Answer: b) Leafy green vegetables
Rationale: Leafy green vegetables contain high levels of
vitamin K, which can interfere with the anticoagulant effect
of warfarin, requiring a consistent intake of vitamin K.
8. A nurse is administering a dose of insulin to a client with
diabetes mellitus. Which of the following actions should the
nurse take before administering the insulin?
A. Assess the client's blood glucose level
B. Administer the insulin after the meal
C. Shake the vial of insulin before use
D. Monitor the client for signs of hyperglycemia
Answer: a) Assess the client's blood glucose level
hypertension. The nurse should monitor the client for which
of the following adverse effects?
A. Weight loss
B. Hyperkalemia
C. Hypoglycemia
D. Dehydration
Answer: b) Hyperkalemia
Rationale: Lisinopril, an ACE inhibitor, can cause
hyperkalemia due to its effect on aldosterone secretion. The
nurse should monitor potassium levels.
2. A nurse is caring for a client receiving a blood
transfusion. The nurse should monitor the client for which of
the following signs of an allergic reaction?
A. Tachycardia
B. Fever and chills
C. Rash and itching
D. Cyanosis
Answer: c) Rash and itching
Rationale: Rash and itching are common signs of an allergic
reaction to a blood transfusion. The nurse should stop the
transfusion and notify the provider if these symptoms occur.
3. A nurse is caring for a client with tuberculosis who is
prescribed isoniazid. The nurse should instruct the client to
report which of the following symptoms immediately?
A. Nausea and vomiting
B. Yellowing of the skin or eyes
C. Dizziness
,D. Muscle pain
Answer: b) Yellowing of the skin or eyes
Rationale: Yellowing of the skin or eyes (jaundice) can
indicate hepatotoxicity, a serious side effect of isoniazid.
4. A nurse is preparing to administer morphine to a client for
pain management. Which of the following assessments
should the nurse prioritize before administration?
A. Blood glucose level
B. Respiratory rate
C. Liver function tests
D. Kidney function tests
Answer: b) Respiratory rate
Rationale: Opioids like morphine can cause respiratory
depression, so it is crucial to assess the client's respiratory
rate prior to administration.
5. A nurse is caring for a client who is taking
hydrochlorothiazide. The nurse should monitor the client for
which of the following electrolyte imbalances?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hyponatremia
Answer: c) Hypokalemia
Rationale: Hydrochlorothiazide is a thiazide diuretic that
can cause potassium loss, leading to hypokalemia.
6. A nurse is preparing to administer a dose of naloxone to a
client with opioid overdose. Which of the following actions
should the nurse take?
A. Monitor the client for respiratory depression after
, administration.
B. Administer the drug subcutaneously for faster action.
C. Administer naloxone only if the client is unresponsive to
pain stimuli.
D. Monitor for an increased heart rate as a sign of
effectiveness.
Answer: a) Monitor the client for respiratory depression
after administration.
Rationale: Naloxone is an opioid antagonist used to reverse
opioid toxicity. After administration, the nurse should
monitor the client for signs of respiratory depression and
the need for additional doses.
7. A client is prescribed warfarin. The nurse should instruct
the client to avoid which of the following foods?
A. Bananas
B. Leafy green vegetables
C. Tomatoes
D. Potatoes
Answer: b) Leafy green vegetables
Rationale: Leafy green vegetables contain high levels of
vitamin K, which can interfere with the anticoagulant effect
of warfarin, requiring a consistent intake of vitamin K.
8. A nurse is administering a dose of insulin to a client with
diabetes mellitus. Which of the following actions should the
nurse take before administering the insulin?
A. Assess the client's blood glucose level
B. Administer the insulin after the meal
C. Shake the vial of insulin before use
D. Monitor the client for signs of hyperglycemia
Answer: a) Assess the client's blood glucose level
