STUDY GUIDE 2026
1. A nurse is caring for a client receiving digoxin. Which finding indicates digoxin toxicity?
Answer: Blurred vision with yellow halos around lights.
Explanation: Visual disturbances such as yellow or green halos, nausea, and bradycardia are
signs of digoxin toxicity; the nurse should hold the dose and notify the provider.
2. A nurse reinforces teaching about warfarin. Which statement shows understanding?
Answer: “I will avoid eating large amounts of leafy green vegetables.”
Explanation: Vitamin K decreases warfarin’s effectiveness; consistent intake is crucial to
maintain therapeutic INR.
3. A client with COPD has O₂ saturation of 88%. What should the nurse do first?
Answer: Encourage pursed-lip breathing.
Explanation: Pursed-lip breathing helps increase CO₂ elimination and maintain oxygenation
without suppressing respiratory drive.
4. The nurse is caring for a client with heart failure. Which dietary instruction is correct?
Answer: Limit sodium to less than 2 g per day.
Explanation: Sodium restriction helps prevent fluid retention and reduces cardiac workload.
5. Which finding should the nurse report immediately for a client receiving IV furosemide?
Answer: Muscle weakness.
Explanation: Indicates hypokalemia, a possible side effect of furosemide requiring prompt
correction.
6. A client with diabetes reports shakiness and sweating. What is the nurse’s priority?
Answer: Check the client’s blood glucose level.
, Explanation: Hypoglycemia should be confirmed with testing before providing glucose
replacement.
7. A nurse prepares to administer blood. Which action ensures client safety?
Answer: Verify client identity with another licensed nurse.
Explanation: Dual verification prevents transfusion errors.
8. What is the expected action of morphine sulfate?
Answer: Binds to opioid receptors to decrease pain perception.
Explanation: Morphine alters pain transmission in the central nervous system, providing
analgesia.
9. A client has tuberculosis. What isolation precaution is required?
Answer: Airborne precautions.
Explanation: TB spreads via airborne particles; use N95 respirator, negative-pressure room, and
limit visitors.
10. A nurse cares for a client with a new tracheostomy. What is the priority action?
Answer: Ensure the tracheostomy ties are secure and two spare tubes are available.
Explanation: Ensures airway patency and readiness for emergency reinsertion.
11. Which finding indicates infiltration of an IV line?
Answer: Cool, pale skin around the insertion site.
Explanation: Coolness and pallor suggest fluid leakage into surrounding tissue.
12. What should the nurse monitor in a client taking lithium?
Answer: Serum sodium levels.
Explanation: Hyponatremia increases lithium toxicity risk; monitor sodium and fluid balance.