1. 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.
2. A client is started on lorazepam for anxiety. Which
teaching
point is essential?
A. “Avoid grapefruit juice.”
B. “Take with NSAIDs.”
C. “Do not stop abruptly.”
D. “It may take weeks to work.”
Answer: C
Rationale: Benzodiazepines must be tapered to prevent
withdrawal symptoms and seizures.
3. 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.
4. A client taking omeprazole asks why it is prescribed.
Which
response is correct?
A. "It coats the lining of the stomach."
B. "It neutralizes gastric acid."
C. "It blocks acid production."
D. "It stimulates protective mucus production."
Answer: C
Rationale: Omeprazole is a proton pump inhibitor (PPI) that
blocks gastric acid secretion.
5. 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.
6. A client uses sublingual nitroglycerin. Which instruction
is
correct?
A. Swallow the pill with water
B. Take up to 3 doses, 5 minutes apart
C. Store it in a warm area
D. Use it once weekly
Answer: B
Rationale: For chest pain, take 1 tablet every 5 minutes, up
to 3
doses, and call 911 if no relief after the first.
7. What should the nurse include when teaching a client
taking
ferrous sulfate?
A. Take with milk
B. Take with food if GI upset occurs
C. Expect pale stools
D. Avoid vitamin C
Answer: B
Rationale: Iron can upset the stomach. If so, take with food
(but
not dairy). Vitamin C increases absorption.
8. 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.
9. 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
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.
2. A client is started on lorazepam for anxiety. Which
teaching
point is essential?
A. “Avoid grapefruit juice.”
B. “Take with NSAIDs.”
C. “Do not stop abruptly.”
D. “It may take weeks to work.”
Answer: C
Rationale: Benzodiazepines must be tapered to prevent
withdrawal symptoms and seizures.
3. 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.
4. A client taking omeprazole asks why it is prescribed.
Which
response is correct?
A. "It coats the lining of the stomach."
B. "It neutralizes gastric acid."
C. "It blocks acid production."
D. "It stimulates protective mucus production."
Answer: C
Rationale: Omeprazole is a proton pump inhibitor (PPI) that
blocks gastric acid secretion.
5. 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.
6. A client uses sublingual nitroglycerin. Which instruction
is
correct?
A. Swallow the pill with water
B. Take up to 3 doses, 5 minutes apart
C. Store it in a warm area
D. Use it once weekly
Answer: B
Rationale: For chest pain, take 1 tablet every 5 minutes, up
to 3
doses, and call 911 if no relief after the first.
7. What should the nurse include when teaching a client
taking
ferrous sulfate?
A. Take with milk
B. Take with food if GI upset occurs
C. Expect pale stools
D. Avoid vitamin C
Answer: B
Rationale: Iron can upset the stomach. If so, take with food
(but
not dairy). Vitamin C increases absorption.
8. 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.
9. 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
