1. A nurse is caring for a client who is prescribed metformin
for type 2 diabetes mellitus. The nurse should monitor for
which of the following adverse effects?
A. Hypoglycemia
B. Hyperkalemia
C. Lactic acidosis
D. Constipation
Answer: c) Lactic acidosis
Rationale: Metformin can cause lactic acidosis, a serious
adverse effect. The nurse should monitor for symptoms
such as muscle pain, weakness, and respiratory distress.
2. A nurse is caring for a client who is prescribed an opioid
analgesic for pain management. Which of the following
interventions should the nurse include in the plan of care to
prevent constipation?
A. Increase fluid intake
B. Restrict dietary fiber
C. Administer a laxative with each dose of medication
D. Encourage a low-protein diet
Answer: a) Increase fluid intake
Rationale: Opioids can cause constipation, and increasing
fluid intake and dietary fiber can help prevent this adverse
effect.
3. A nurse is caring for a client who is prescribed lithium for
bipolar disorder. The nurse should monitor for signs of
toxicity, which include:
A. Fine hand tremors and polyuria
B. Fine hand tremors and increased appetite
,C. Fine hand tremors and weight loss
D. Fine hand tremors and lethargy
Answer: a) Fine hand tremors and polyuria
Rationale: Fine hand tremors and polyuria are early signs of
lithium toxicity. The nurse should monitor serum lithium
levels to prevent toxicity.
4. A nurse is caring for a client receiving enalapril. Which of
the following should be monitored regularly?
A. Blood pressure
B. Blood glucose level
C. Respiratory rate
D. Serum calcium
Answer: a) Blood pressure
Rationale: Enalapril is an ACE inhibitor, primarily used for
hypertension management. Blood pressure should be
closely monitored to ensure the medication is effective.
5. A nurse is administering a dose of insulin to a client with
diabetes mellitus. Which of the following actions should the
nurse take before administering the insulin?
A. Assess the client's blood glucose level
B. Administer the insulin after the meal
C. Shake the vial of insulin before use
D. Monitor the client for signs of hyperglycemia
Answer: a) Assess the client's blood glucose level
Rationale: It is important to assess the client's blood
glucose level before administering insulin to ensure that the
correct dose is given based on the client's current glucose
level.
6. A nurse is caring for a client who has just received a dose
, of methylprednisolone. The nurse should monitor the client
for which of the following adverse effects?
A. Hypotension
B. Hyperglycemia
C. Bradycardia
D. Weight loss
Answer: b) Hyperglycemia
Rationale: Methylprednisolone, a corticosteroid, can raise
blood glucose levels, potentially leading to hyperglycemia.
7. A nurse is administering a dose of phenytoin to a client
with seizures. The nurse should monitor the client for which
of the following adverse effects?
A. Gingival hyperplasia
B. Weight loss
C. Tremors
D. Hypoglycemia
Answer: a) Gingival hyperplasia
Rationale: Phenytoin is associated with gingival
hyperplasia, an overgrowth of the gum tissue, as a common
adverse effect.
8. A nurse is administering the first dose of an
antihypertensive medication to a client. Which of the
following is the priority action?
A. Monitor the client’s blood pressure for hypotension.
B. Provide the client with food to reduce gastrointestinal
irritation.
C. Assess the client for signs of dizziness or
lightheadedness.
D. Ensure the client understands the potential for sexual
dysfunction.
for type 2 diabetes mellitus. The nurse should monitor for
which of the following adverse effects?
A. Hypoglycemia
B. Hyperkalemia
C. Lactic acidosis
D. Constipation
Answer: c) Lactic acidosis
Rationale: Metformin can cause lactic acidosis, a serious
adverse effect. The nurse should monitor for symptoms
such as muscle pain, weakness, and respiratory distress.
2. A nurse is caring for a client who is prescribed an opioid
analgesic for pain management. Which of the following
interventions should the nurse include in the plan of care to
prevent constipation?
A. Increase fluid intake
B. Restrict dietary fiber
C. Administer a laxative with each dose of medication
D. Encourage a low-protein diet
Answer: a) Increase fluid intake
Rationale: Opioids can cause constipation, and increasing
fluid intake and dietary fiber can help prevent this adverse
effect.
3. A nurse is caring for a client who is prescribed lithium for
bipolar disorder. The nurse should monitor for signs of
toxicity, which include:
A. Fine hand tremors and polyuria
B. Fine hand tremors and increased appetite
,C. Fine hand tremors and weight loss
D. Fine hand tremors and lethargy
Answer: a) Fine hand tremors and polyuria
Rationale: Fine hand tremors and polyuria are early signs of
lithium toxicity. The nurse should monitor serum lithium
levels to prevent toxicity.
4. A nurse is caring for a client receiving enalapril. Which of
the following should be monitored regularly?
A. Blood pressure
B. Blood glucose level
C. Respiratory rate
D. Serum calcium
Answer: a) Blood pressure
Rationale: Enalapril is an ACE inhibitor, primarily used for
hypertension management. Blood pressure should be
closely monitored to ensure the medication is effective.
5. A nurse is administering a dose of insulin to a client with
diabetes mellitus. Which of the following actions should the
nurse take before administering the insulin?
A. Assess the client's blood glucose level
B. Administer the insulin after the meal
C. Shake the vial of insulin before use
D. Monitor the client for signs of hyperglycemia
Answer: a) Assess the client's blood glucose level
Rationale: It is important to assess the client's blood
glucose level before administering insulin to ensure that the
correct dose is given based on the client's current glucose
level.
6. A nurse is caring for a client who has just received a dose
, of methylprednisolone. The nurse should monitor the client
for which of the following adverse effects?
A. Hypotension
B. Hyperglycemia
C. Bradycardia
D. Weight loss
Answer: b) Hyperglycemia
Rationale: Methylprednisolone, a corticosteroid, can raise
blood glucose levels, potentially leading to hyperglycemia.
7. A nurse is administering a dose of phenytoin to a client
with seizures. The nurse should monitor the client for which
of the following adverse effects?
A. Gingival hyperplasia
B. Weight loss
C. Tremors
D. Hypoglycemia
Answer: a) Gingival hyperplasia
Rationale: Phenytoin is associated with gingival
hyperplasia, an overgrowth of the gum tissue, as a common
adverse effect.
8. A nurse is administering the first dose of an
antihypertensive medication to a client. Which of the
following is the priority action?
A. Monitor the client’s blood pressure for hypotension.
B. Provide the client with food to reduce gastrointestinal
irritation.
C. Assess the client for signs of dizziness or
lightheadedness.
D. Ensure the client understands the potential for sexual
dysfunction.
