1. A nurse is teaching a client about hydroxychloroquine for lupus.
What adverse effect should be reported immediately?
A. Dizziness
B. Blurred vision
C. Dry mouth
D. Rash
Answer: B
Rationale: Retinal damage is a serious side effect. Clients need
regular eye exams.
2. A nurse is administering digoxin to a client. Which finding
requires immediate action?
A. HR 62 bpm
B. Blurred vision with yellow halos
C. BP 140/88 mmHg
D. Urine output 400 mL in 8 hours
Answer: B
Rationale: Visual disturbances and halos are signs of digoxin
toxicity, especially when paired with bradycardia.
3. A client on lithium therapy has a sodium level of 128 mEq/L.
What is the nurse's best action?
A. Encourage low-sodium diet
B. Administer next dose
C. Hold the dose and notify the provider
D. Increase fluid restriction
,Answer: C
Rationale: Hyponatremia can increase lithium toxicity risk. Hold
the dose and notify the provider.
4. A client with myasthenia gravis is prescribed neostigmine.
Which finding indicates underdosing?
A. Bradycardia
B. Muscle weakness
C. Diarrhea
D. Excessive salivation
Answer: B
Rationale: Muscle weakness could indicate myasthenic crisis,
requiring dosage adjustment.
5. A client on clozapine reports fever and sore throat. What is the
priority action?
A. Reassure and monitor
B. Administer antipyretics
C. Check WBC count
D. Suggest lozenges
Answer: C
Rationale: Clozapine can cause agranulocytosis. A fever + sore
throat may signal low WBC—check labs.
6. A client takes aluminum hydroxide for GERD. What adverse
effect should the nurse monitor?
A. Diarrhea
B. Constipation
, C. Hypokalemia
D. Rash
Answer: B
Rationale: Aluminum-based antacids commonly cause
constipation.
7. A client with asthma uses albuterol PRN. Which statement
shows proper understanding?
A. “I use this every morning and night.”
B. “I use this when I’m having shortness of breath.”
C. “I use it with my steroid inhaler at the same time.”
D. “I use this even if I’m not having symptoms.”
Answer: B
Rationale: Albuterol is a rescue inhaler used during asthma attacks
or acute symptoms.
8. A client is started on lorazepam for anxiety. Which teaching
point is essential?
A. “Avoid grapefruit juice.”
B. “Take with NSAIDs.”
C. “Do not stop abruptly.”
D. “It may take weeks to work.”
Answer: C
Rationale: Benzodiazepines must be tapered to prevent
withdrawal symptoms and seizures.
9. A client started on fluoxetine 5 days ago reports increased
energy and planning their funeral. What should the nurse do?
What adverse effect should be reported immediately?
A. Dizziness
B. Blurred vision
C. Dry mouth
D. Rash
Answer: B
Rationale: Retinal damage is a serious side effect. Clients need
regular eye exams.
2. A nurse is administering digoxin to a client. Which finding
requires immediate action?
A. HR 62 bpm
B. Blurred vision with yellow halos
C. BP 140/88 mmHg
D. Urine output 400 mL in 8 hours
Answer: B
Rationale: Visual disturbances and halos are signs of digoxin
toxicity, especially when paired with bradycardia.
3. A client on lithium therapy has a sodium level of 128 mEq/L.
What is the nurse's best action?
A. Encourage low-sodium diet
B. Administer next dose
C. Hold the dose and notify the provider
D. Increase fluid restriction
,Answer: C
Rationale: Hyponatremia can increase lithium toxicity risk. Hold
the dose and notify the provider.
4. A client with myasthenia gravis is prescribed neostigmine.
Which finding indicates underdosing?
A. Bradycardia
B. Muscle weakness
C. Diarrhea
D. Excessive salivation
Answer: B
Rationale: Muscle weakness could indicate myasthenic crisis,
requiring dosage adjustment.
5. A client on clozapine reports fever and sore throat. What is the
priority action?
A. Reassure and monitor
B. Administer antipyretics
C. Check WBC count
D. Suggest lozenges
Answer: C
Rationale: Clozapine can cause agranulocytosis. A fever + sore
throat may signal low WBC—check labs.
6. A client takes aluminum hydroxide for GERD. What adverse
effect should the nurse monitor?
A. Diarrhea
B. Constipation
, C. Hypokalemia
D. Rash
Answer: B
Rationale: Aluminum-based antacids commonly cause
constipation.
7. A client with asthma uses albuterol PRN. Which statement
shows proper understanding?
A. “I use this every morning and night.”
B. “I use this when I’m having shortness of breath.”
C. “I use it with my steroid inhaler at the same time.”
D. “I use this even if I’m not having symptoms.”
Answer: B
Rationale: Albuterol is a rescue inhaler used during asthma attacks
or acute symptoms.
8. A client is started on lorazepam for anxiety. Which teaching
point is essential?
A. “Avoid grapefruit juice.”
B. “Take with NSAIDs.”
C. “Do not stop abruptly.”
D. “It may take weeks to work.”
Answer: C
Rationale: Benzodiazepines must be tapered to prevent
withdrawal symptoms and seizures.
9. A client started on fluoxetine 5 days ago reports increased
energy and planning their funeral. What should the nurse do?
