1. A client is prescribed exenatide. What is a common side
effect?
A. Hyperglycemia
B. Constipation
C. Nausea
D. Tachycardia
Answer: C
Rationale: Exenatide can cause nausea, especially when
initiating
therapy. It’s an injectable incretin mimetic.
2. 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.
3. A client is taking diphenhydramine. Which side effect is
most
likely?
A. Hypertension
B. Drowsiness
C. Diarrhea
D. Insomnia
Answer: B
,Rationale: First-generation antihistamines like
diphenhydramine
cause sedation and drowsiness.
4. 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.
5. A client is prescribed loratadine for seasonal allergies.
What is
A. key difference from diphenhydramine?
A. Loratadine causes more drowsiness
B. Loratadine causes GI upset
C. Loratadine is non-sedating
D. Loratadine is only available IV
Answer: C
Rationale: Second-generation antihistamines like loratadine
are
non-sedating.
6. 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.
7. 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.
8. 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.
9. Which statement indicates proper understanding of
enoxaparin (Lovenox) administration?
A. “I will inject it into my thigh muscle.”
effect?
A. Hyperglycemia
B. Constipation
C. Nausea
D. Tachycardia
Answer: C
Rationale: Exenatide can cause nausea, especially when
initiating
therapy. It’s an injectable incretin mimetic.
2. 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.
3. A client is taking diphenhydramine. Which side effect is
most
likely?
A. Hypertension
B. Drowsiness
C. Diarrhea
D. Insomnia
Answer: B
,Rationale: First-generation antihistamines like
diphenhydramine
cause sedation and drowsiness.
4. 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.
5. A client is prescribed loratadine for seasonal allergies.
What is
A. key difference from diphenhydramine?
A. Loratadine causes more drowsiness
B. Loratadine causes GI upset
C. Loratadine is non-sedating
D. Loratadine is only available IV
Answer: C
Rationale: Second-generation antihistamines like loratadine
are
non-sedating.
6. 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.
7. 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.
8. 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.
9. Which statement indicates proper understanding of
enoxaparin (Lovenox) administration?
A. “I will inject it into my thigh muscle.”
