1. A client on sertraline reports increased restlessness
and
confusion. What should the nurse suspect?
A. Extrapyramidal symptoms
B. Lithium toxicity
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Answer: C
Rationale: Serotonin syndrome includes agitation,
confusion,
tachycardia, and hyperreflexia.
2. 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.
3. 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.
4. 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.
, 5. A client receiving methotrexate for cancer reports
mouth
sores. What is the nurse's best response?
A. “This is a normal side effect.”
B. “Increase intake of spicy food.”
C. “Use a soft toothbrush and rinse with saline.”
D. “Chew gum frequently.”
Answer: C
Rationale: Mouth sores (stomatitis) are common. Gentle oral
care
is essential to prevent infection and discomfort.
6. 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.
7. 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.
8. 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.
9. 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
and
confusion. What should the nurse suspect?
A. Extrapyramidal symptoms
B. Lithium toxicity
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Answer: C
Rationale: Serotonin syndrome includes agitation,
confusion,
tachycardia, and hyperreflexia.
2. 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.
3. 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.
4. 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.
, 5. A client receiving methotrexate for cancer reports
mouth
sores. What is the nurse's best response?
A. “This is a normal side effect.”
B. “Increase intake of spicy food.”
C. “Use a soft toothbrush and rinse with saline.”
D. “Chew gum frequently.”
Answer: C
Rationale: Mouth sores (stomatitis) are common. Gentle oral
care
is essential to prevent infection and discomfort.
6. 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.
7. 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.
8. 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.
9. 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
