1. A client on clozapine reports fever and sore throat. What is the
priority action?
A. Reassure and monitor
B. Administer antipyretics
C. Check WBC count
D. Suggest lozenges
Answer: C
Rationale: Clozapine can cause agranulocytosis. A fever + sore
throat may signal low WBC—check labs.
2. A client with a penicillin allergy is prescribed cephalexin. What
is the nurse’s priority?
A. Administer as ordered
B. Ask about previous reaction type
C. Hold the dose for 30 minutes
D. Give with food
Answer: B
Rationale: Cross-sensitivity may occur. Ask if the client had a true
anaphylactic reaction before administering.
3. A client with asthma uses albuterol PRN. Which statement
shows proper understanding?
A. “I use this every morning and night.”
B. “I use this when I’m having shortness of breath.”
C. “I use it with my steroid inhaler at the same time.”
D. “I use this even if I’m not having symptoms.”
Answer: B
Rationale: Albuterol is a rescue inhaler used during asthma attacks
or acute symptoms.
4. 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.
5. 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.
6. 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.
7. A nurse is caring for a client prescribed lisinopril. Which lab
result should the nurse report to the provider?
A. Sodium 138 mEq/L
B. Potassium 5.8 mEq/L
, C. Hemoglobin 14 g/dL
D. BUN 18 mg/dL
Answer: B
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia. A
potassium level of 5.8 is elevated and should be reported.
8. A nurse monitors a client taking lamotrigine. What adverse
effect should prompt discontinuation?
A. Rash
B. Constipation
C. Nausea
D. Drowsiness
Answer: A
Rationale: Lamotrigine can cause a life-threatening rash (e.g.,
Stevens-Johnson syndrome). Report immediately.
9. A client taking carbidopa/levodopa reports facial twitching
and eye spasms. What should the nurse do?
A. Reassure the client this is expected
B. Hold the dose and notify the provider
C. Administer diphenhydramine
D. Document and continue monitoring
Answer: B
Rationale: Facial twitching and spasms are signs of toxicity. Notify
the provider to adjust dosage.
10. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
D. Blood glucose
Answer: B
priority action?
A. Reassure and monitor
B. Administer antipyretics
C. Check WBC count
D. Suggest lozenges
Answer: C
Rationale: Clozapine can cause agranulocytosis. A fever + sore
throat may signal low WBC—check labs.
2. A client with a penicillin allergy is prescribed cephalexin. What
is the nurse’s priority?
A. Administer as ordered
B. Ask about previous reaction type
C. Hold the dose for 30 minutes
D. Give with food
Answer: B
Rationale: Cross-sensitivity may occur. Ask if the client had a true
anaphylactic reaction before administering.
3. A client with asthma uses albuterol PRN. Which statement
shows proper understanding?
A. “I use this every morning and night.”
B. “I use this when I’m having shortness of breath.”
C. “I use it with my steroid inhaler at the same time.”
D. “I use this even if I’m not having symptoms.”
Answer: B
Rationale: Albuterol is a rescue inhaler used during asthma attacks
or acute symptoms.
4. 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.
5. 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.
6. 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.
7. A nurse is caring for a client prescribed lisinopril. Which lab
result should the nurse report to the provider?
A. Sodium 138 mEq/L
B. Potassium 5.8 mEq/L
, C. Hemoglobin 14 g/dL
D. BUN 18 mg/dL
Answer: B
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia. A
potassium level of 5.8 is elevated and should be reported.
8. A nurse monitors a client taking lamotrigine. What adverse
effect should prompt discontinuation?
A. Rash
B. Constipation
C. Nausea
D. Drowsiness
Answer: A
Rationale: Lamotrigine can cause a life-threatening rash (e.g.,
Stevens-Johnson syndrome). Report immediately.
9. A client taking carbidopa/levodopa reports facial twitching
and eye spasms. What should the nurse do?
A. Reassure the client this is expected
B. Hold the dose and notify the provider
C. Administer diphenhydramine
D. Document and continue monitoring
Answer: B
Rationale: Facial twitching and spasms are signs of toxicity. Notify
the provider to adjust dosage.
10. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
D. Blood glucose
Answer: B
