1. A client taking warfarin has an INR of 4.2. Which action should
the nurse take?
A. Administer the next dose of warfarin
B. Hold the dose and notify the provider
C. Give vitamin K IV immediately
D. Prepare for platelet transfusion
Answer: B
Rationale: An INR >3.0 indicates increased bleeding risk. The
nurse should hold the medication and notify the provider.
2. A client receiving amphotericin B develops chills and fever.
What should the nurse do?
A. Stop the infusion
B. Document findings
C. Pre-medicate with acetaminophen
D. Increase infusion rate
Answer: C
Rationale: Infusion reactions are common. Premedication with
acetaminophen or diphenhydramine is standard.
3. A post-op client is given ondansetron. Which is an expected
outcome?
A. Decreased heart rate
B. Absence of nausea
C. Increased bowel sounds
D. Sedation
,Answer: B
Rationale: Ondansetron is a serotonin antagonist used to prevent
or treat nausea and vomiting.
4. A client uses sublingual nitroglycerin. Which instruction is
correct?
A. Swallow the pill with water
B. Take up to 3 doses, 5 minutes apart
C. Store it in a warm area
D. Use it once weekly
Answer: B
Rationale: For chest pain, take 1 tablet every 5 minutes, up to 3
doses, and call 911 if no relief after the first.
5. A client with hypothyroidism takes levothyroxine. Which
statement indicates effective therapy?
A. “I feel cold all the time.”
B. “My heart rate is slower than usual.”
C. “I have more energy now.”
D. “I’m gaining weight quickly.”
Answer: C
Rationale: Increased energy suggests improved thyroid function.
6. A client asks about insulin glargine (Lantus). What is the correct
response?
A. “It works immediately.”
B. “It peaks in 4 hours.”
C. “It has no peak and lasts 24 hours.”
, D. “It must be mixed with regular insulin.”
Answer: C
Rationale: Glargine is a long-acting insulin with no pronounced
peak, providing steady glucose control.
7. A client taking furosemide reports muscle cramps. Which lab
value correlates with this symptom?
A. Sodium 142
B. Potassium 2.9
C. Chloride 101
D. Magnesium 2.0
Answer: B
Rationale: Furosemide can cause hypokalemia, which leads to
muscle cramps. Normal potassium: 3.5–5.0.
8. A client taking haloperidol develops a high fever and muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
C. Tardive dyskinesia
D. Extrapyramidal symptoms (EPS)
Answer: B
Rationale: NMS is a rare but fatal reaction to antipsychotics.
Requires immediate intervention.
9. A client with herpes simplex is prescribed acyclovir. What is the
most important teaching?
A. "Take on an empty stomach."
the nurse take?
A. Administer the next dose of warfarin
B. Hold the dose and notify the provider
C. Give vitamin K IV immediately
D. Prepare for platelet transfusion
Answer: B
Rationale: An INR >3.0 indicates increased bleeding risk. The
nurse should hold the medication and notify the provider.
2. A client receiving amphotericin B develops chills and fever.
What should the nurse do?
A. Stop the infusion
B. Document findings
C. Pre-medicate with acetaminophen
D. Increase infusion rate
Answer: C
Rationale: Infusion reactions are common. Premedication with
acetaminophen or diphenhydramine is standard.
3. A post-op client is given ondansetron. Which is an expected
outcome?
A. Decreased heart rate
B. Absence of nausea
C. Increased bowel sounds
D. Sedation
,Answer: B
Rationale: Ondansetron is a serotonin antagonist used to prevent
or treat nausea and vomiting.
4. A client uses sublingual nitroglycerin. Which instruction is
correct?
A. Swallow the pill with water
B. Take up to 3 doses, 5 minutes apart
C. Store it in a warm area
D. Use it once weekly
Answer: B
Rationale: For chest pain, take 1 tablet every 5 minutes, up to 3
doses, and call 911 if no relief after the first.
5. A client with hypothyroidism takes levothyroxine. Which
statement indicates effective therapy?
A. “I feel cold all the time.”
B. “My heart rate is slower than usual.”
C. “I have more energy now.”
D. “I’m gaining weight quickly.”
Answer: C
Rationale: Increased energy suggests improved thyroid function.
6. A client asks about insulin glargine (Lantus). What is the correct
response?
A. “It works immediately.”
B. “It peaks in 4 hours.”
C. “It has no peak and lasts 24 hours.”
, D. “It must be mixed with regular insulin.”
Answer: C
Rationale: Glargine is a long-acting insulin with no pronounced
peak, providing steady glucose control.
7. A client taking furosemide reports muscle cramps. Which lab
value correlates with this symptom?
A. Sodium 142
B. Potassium 2.9
C. Chloride 101
D. Magnesium 2.0
Answer: B
Rationale: Furosemide can cause hypokalemia, which leads to
muscle cramps. Normal potassium: 3.5–5.0.
8. A client taking haloperidol develops a high fever and muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
C. Tardive dyskinesia
D. Extrapyramidal symptoms (EPS)
Answer: B
Rationale: NMS is a rare but fatal reaction to antipsychotics.
Requires immediate intervention.
9. A client with herpes simplex is prescribed acyclovir. What is the
most important teaching?
A. "Take on an empty stomach."
