1. 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
Rationale: Scopolamine has anticholinergic effects like dry
mouth,
blurred vision, and urinary retention.
2. 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.
3. A client is prescribed loperamide. Which condition is a
contraindication?
A. IBS
B. Infectious diarrhea
C. Traveler’s diarrhea
D. Post-antibiotic diarrhea
Answer: B
Rationale: Do not use antidiarrheals in infectious diarrhea,
as it
may retain toxins in the bowel.
4. Which statement indicates proper understanding of
enoxaparin (Lovenox) administration?
A. “I will inject it into my thigh muscle.”
B. “I will rub the site after injection.”
C. “I will inject it into my belly fat.”
D. “I must monitor my INR daily.”
Answer: C
Rationale: Enoxaparin is given subcutaneously, preferably
in the
abdomen, and INR monitoring is not required.
5. 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.
6. 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.
7. 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.
8. What should the nurse include when teaching a client
taking
ferrous sulfate?
A. Take with milk
B. Take with food if GI upset occurs
C. Expect pale stools
D. Avoid vitamin C
Answer: B
Rationale: Iron can upset the stomach. If so, take with food
(but
not dairy). Vitamin C increases absorption.
9. A client taking haloperidol develops a high fever and
muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
What side effect should the nurse monitor?
A. Diarrhea
B. Blurred vision and dry mouth
C. Rash
D. Hearing loss
Answer: B
Rationale: Scopolamine has anticholinergic effects like dry
mouth,
blurred vision, and urinary retention.
2. 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.
3. A client is prescribed loperamide. Which condition is a
contraindication?
A. IBS
B. Infectious diarrhea
C. Traveler’s diarrhea
D. Post-antibiotic diarrhea
Answer: B
Rationale: Do not use antidiarrheals in infectious diarrhea,
as it
may retain toxins in the bowel.
4. Which statement indicates proper understanding of
enoxaparin (Lovenox) administration?
A. “I will inject it into my thigh muscle.”
B. “I will rub the site after injection.”
C. “I will inject it into my belly fat.”
D. “I must monitor my INR daily.”
Answer: C
Rationale: Enoxaparin is given subcutaneously, preferably
in the
abdomen, and INR monitoring is not required.
5. 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.
6. 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.
7. 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.
8. What should the nurse include when teaching a client
taking
ferrous sulfate?
A. Take with milk
B. Take with food if GI upset occurs
C. Expect pale stools
D. Avoid vitamin C
Answer: B
Rationale: Iron can upset the stomach. If so, take with food
(but
not dairy). Vitamin C increases absorption.
9. A client taking haloperidol develops a high fever and
muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
