1. A client with chronic constipation uses magnesium citrate
daily. What risk should the nurse discuss?
A. Hypertension
B. Hypernatremia
C. Electrolyte imbalance
D. Dehydration
Answer: C
Rationale: Chronic laxative use, especially osmotic types like
magnesium citrate, causes fluid and electrolyte imbalances.
2. A client on sildenafil experiences chest pain during
intercourse. What is the nurse’s next action?
A. Administer nitroglycerin
B. Encourage rest and fluids
C. Call emergency services
D. Administer aspirin
Answer: C
Rationale: Sildenafil + nitrates can cause life-threatening
hypotension. Do not give nitro—call 911.
3. A client started on fluoxetine 5 days ago reports increased
energy and planning their funeral. What should the nurse do?
A. Encourage journaling
B. Monitor sleep
C. Notify the provider immediately
D. Provide distraction techniques
Answer: C
Rationale: Increased energy + suicidal ideation early in SSRI
therapy is dangerous and should be reported.
4. A client is receiving morphine IV post-op. Which finding is the
,priority?
A. Nausea
B. Respiratory rate of 8/min
C. Itching
D. Sedation score of 2
Answer: B
Rationale: Respiratory depression (<12/min) is the most life
threatening side effect of opioids.
5. 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.
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 nurse is teaching a client how to apply clotrimazole vaginal
cream. What instruction is correct?
A. Use during menstruation
B. Stop once symptoms go away
, C. Use applicator at bedtime
D. Use with a tampon
Answer: C
Rationale: For maximum effect, apply at bedtime using the
applicator. Avoid tampons during treatment.
8. A client with a penicillin allergy is prescribed cephalexin. What
is the nurse’s priority?
A. Administer as ordered
B. Ask about previous reaction type
C. Hold the dose for 30 minutes
D. Give with food
Answer: B
Rationale: Cross-sensitivity may occur. Ask if the client had a true
anaphylactic reaction before administering.
9. A nurse is caring for a client prescribed lisinopril. Which lab
result should the nurse report to the provider?
A. Sodium 138 mEq/L
B. Potassium 5.8 mEq/L
C. Hemoglobin 14 g/dL
D. BUN 18 mg/dL
Answer: B
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia. A
potassium level of 5.8 is elevated and should be reported.
10. A client is using a scopolamine patch for motion sickness.
What side effect should the nurse monitor?
A. Diarrhea
B. Blurred vision and dry mouth
C. Rash
D. Hearing loss
Answer: B
daily. What risk should the nurse discuss?
A. Hypertension
B. Hypernatremia
C. Electrolyte imbalance
D. Dehydration
Answer: C
Rationale: Chronic laxative use, especially osmotic types like
magnesium citrate, causes fluid and electrolyte imbalances.
2. A client on sildenafil experiences chest pain during
intercourse. What is the nurse’s next action?
A. Administer nitroglycerin
B. Encourage rest and fluids
C. Call emergency services
D. Administer aspirin
Answer: C
Rationale: Sildenafil + nitrates can cause life-threatening
hypotension. Do not give nitro—call 911.
3. A client started on fluoxetine 5 days ago reports increased
energy and planning their funeral. What should the nurse do?
A. Encourage journaling
B. Monitor sleep
C. Notify the provider immediately
D. Provide distraction techniques
Answer: C
Rationale: Increased energy + suicidal ideation early in SSRI
therapy is dangerous and should be reported.
4. A client is receiving morphine IV post-op. Which finding is the
,priority?
A. Nausea
B. Respiratory rate of 8/min
C. Itching
D. Sedation score of 2
Answer: B
Rationale: Respiratory depression (<12/min) is the most life
threatening side effect of opioids.
5. 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.
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 nurse is teaching a client how to apply clotrimazole vaginal
cream. What instruction is correct?
A. Use during menstruation
B. Stop once symptoms go away
, C. Use applicator at bedtime
D. Use with a tampon
Answer: C
Rationale: For maximum effect, apply at bedtime using the
applicator. Avoid tampons during treatment.
8. A client with a penicillin allergy is prescribed cephalexin. What
is the nurse’s priority?
A. Administer as ordered
B. Ask about previous reaction type
C. Hold the dose for 30 minutes
D. Give with food
Answer: B
Rationale: Cross-sensitivity may occur. Ask if the client had a true
anaphylactic reaction before administering.
9. A nurse is caring for a client prescribed lisinopril. Which lab
result should the nurse report to the provider?
A. Sodium 138 mEq/L
B. Potassium 5.8 mEq/L
C. Hemoglobin 14 g/dL
D. BUN 18 mg/dL
Answer: B
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia. A
potassium level of 5.8 is elevated and should be reported.
10. A client is using a scopolamine patch for motion sickness.
What side effect should the nurse monitor?
A. Diarrhea
B. Blurred vision and dry mouth
C. Rash
D. Hearing loss
Answer: B
