Practice Questions with Detailed Rationales for Los
Angeles Trade-Technical College (LATTC) Nursing
Students
Includes:
Priority Nursing Actions
Adverse Effects
Drug Interactions
NCLEX-Style Application-Level Questions
2025 Exam Format Updates & Rationales
1. A nurse is reviewing lab results for a client on warfarin. Which INR indicates effective
therapy?
A. INR 1.0
B. INR 1.5
C. INR 2.5 ✅
D. INR 5.0
Correct Answer: C. INR 2.5
Rationale:
Warfarin is an anticoagulant used to prevent clot formation.
The therapeutic INR range for most conditions (like atrial fibrillation or DVT) is 2.0–3.0.
An INR of 1.0 or 1.5 is too low, suggesting subtherapeutic effect.
,An INR of 5.0 is too high, increasing bleeding risk.
2. A client on phenytoin reports gum swelling. What should the nurse do?
A. Increase calcium intake
B. Begin flossing daily
C. Visit a dentist for evaluation ✅
D. Stop taking the medication
Correct Answer: C. Visit a dentist for evaluation
Rationale:
Gingival hyperplasia is a common side effect of phenytoin.
Good oral hygiene helps prevent severity, but the patient should be evaluated by a dentist.
Never stop phenytoin abruptly, as it may trigger seizures.
3. What is the priority assessment for a client receiving IV morphine?
A. Blood pressure
B. Pain score
C. Respiratory rate ✅
D. Temperature
Correct Answer: C. Respiratory rate
Rationale:
,Opioids like morphine can cause respiratory depression, which is the most life-threatening
adverse effect.
Always assess RR before administering.
Although BP and pain scores are important, ABC (Airway, Breathing, Circulation) comes first.
4. A client taking lithium reports nausea and diarrhea. What does this suggest?
A. Dehydration
B. Lithium toxicity ✅
C. Dietary intolerance
D. Withdrawal symptoms
Correct Answer: B. Lithium toxicity
Rationale:
Early signs of lithium toxicity include GI distress (nausea, vomiting, diarrhea), tremors,
confusion.
Normal serum lithium: 0.6–1.2 mEq/L.
Toxicity risk increases with dehydration, low sodium, or renal impairment.
5. The nurse is giving furosemide IV. What adverse effect should be monitored?
A. Bradycardia
B. Hyperkalemia
C. Ototoxicity ✅
D. Hypoglycemia
, Correct Answer: C. Ototoxicity
Rationale:
High doses or rapid IV push of furosemide may cause hearing loss (ototoxicity).
Furosemide causes hypokalemia, not hyperkalemia.
It does not directly affect glucose levels.
6. Which of the following findings should the nurse report for a client on digoxin?
A. HR 58 bpm
B. Potassium 3.2 mEq/L
C. Visual disturbances
D. All of the above ✅
Correct Answer: D. All of the above
Rationale:
HR < 60 bpm suggests bradycardia, a sign of digoxin toxicity.
Hypokalemia increases risk of digoxin toxicity.
Visual disturbances (e.g., yellow halos) are classic signs.
Always assess apical HR and potassium before giving.