1. A nurse is reviewing a client’s chart who is prescribed
gentamicin. Which finding should concern the nurse most?
A. Tinnitus
B. WBC 10,000
C. Urine output 50 mL/hr
D. Temperature 100.2°F
Answer: A
Rationale: Tinnitus is a sign of ototoxicity, a serious adverse
effect
of gentamicin.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. A nurse is educating a client on atorvastatin. What side
effect
should the client report immediately?
A. Headache
B. Muscle pain
C. Drowsiness
D. Constipation
Answer: B
Rationale: Myopathy can occur with statins and may
progress to
rhabdomyolysis. Report muscle pain immediately.
8. 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.
9. 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
gentamicin. Which finding should concern the nurse most?
A. Tinnitus
B. WBC 10,000
C. Urine output 50 mL/hr
D. Temperature 100.2°F
Answer: A
Rationale: Tinnitus is a sign of ototoxicity, a serious adverse
effect
of gentamicin.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. A nurse is educating a client on atorvastatin. What side
effect
should the client report immediately?
A. Headache
B. Muscle pain
C. Drowsiness
D. Constipation
Answer: B
Rationale: Myopathy can occur with statins and may
progress to
rhabdomyolysis. Report muscle pain immediately.
8. 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.
9. 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
