1. 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.
2. 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.
3. 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.
4. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
D. Blood glucose
Answer: B
Rationale: Metoprolol can cause bradycardia. Always check
HR
before administering.
5. A nurse monitors a client taking lamotrigine. What
adverse
effect should prompt discontinuation?
A. Rash
, B. Constipation
C. Nausea
D. Drowsiness
Answer: A
Rationale: Lamotrigine can cause a life-threatening rash
(e.g.,
Stevens-Johnson syndrome). Report immediately.
6. 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.
7. 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.
8. 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.
9. 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.”
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.
2. 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.
3. 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.
4. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
D. Blood glucose
Answer: B
Rationale: Metoprolol can cause bradycardia. Always check
HR
before administering.
5. A nurse monitors a client taking lamotrigine. What
adverse
effect should prompt discontinuation?
A. Rash
, B. Constipation
C. Nausea
D. Drowsiness
Answer: A
Rationale: Lamotrigine can cause a life-threatening rash
(e.g.,
Stevens-Johnson syndrome). Report immediately.
6. 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.
7. 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.
8. 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.
9. 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.”
