1. A client with chronic constipation uses magnesium
citrate
daily. What risk should the nurse discuss?
A. Hypertension
B. Hypernatremia
C. Electrolyte imbalance
D. Dehydration
Answer: C
Rationale: Chronic laxative use, especially osmotic types
like
magnesium citrate, causes fluid and electrolyte imbalances.
2. A client on sertraline reports increased restlessness
and
confusion. What should the nurse suspect?
A. Extrapyramidal symptoms
B. Lithium toxicity
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Answer: C
Rationale: Serotonin syndrome includes agitation,
confusion,
tachycardia, and hyperreflexia.
3. 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.
4. A client on sildenafil experiences chest pain during
intercourse. What is the nurse’s next action?
A. Administer nitroglycerin
B. Encourage rest and fluids
C. Call emergency services
D. Administer aspirin
Answer: C
Rationale: Sildenafil + nitrates can cause life-threatening
hypotension. Do not give nitro—call 911.
5. A client receiving amphotericin B develops chills and
fever.
What should the nurse do?
A. Stop the infusion
B. Document findings
C. Pre-medicate with acetaminophen
D. Increase infusion rate
Answer: C
Rationale: Infusion reactions are common. Premedication
with
acetaminophen or diphenhydramine is standard.
6. A client taking isoniazid (INH) for tuberculosis develops
numbness and tingling in their hands and feet. What should
the
nurse anticipate?
A. The need for increased calcium
B. Administration of pyridoxine (vitamin B6)
, C. Discontinuation of therapy
D. Addition of prednisone
Answer: B
Rationale: Isoniazid can cause peripheral neuropathy, often
prevented or treated with vitamin B6.
7. A nurse teaches a client taking cyclobenzaprine. Which
statement indicates understanding?
A. “I will take this long-term.”
B. “I can drink alcohol in moderation.”
C. “I should avoid driving until I know how it affects me.”
D. “It will help my heart condition.”
Answer: C
Rationale: Cyclobenzaprine causes drowsiness. Clients
should
avoid driving or alcohol initially.
8. A client receiving methotrexate for cancer reports
mouth
sores. What is the nurse's best response?
A. “This is a normal side effect.”
B. “Increase intake of spicy food.”
C. “Use a soft toothbrush and rinse with saline.”
D. “Chew gum frequently.”
Answer: C
Rationale: Mouth sores (stomatitis) are common. Gentle oral
care
is essential to prevent infection and discomfort.
9. What should the nurse include when teaching a client
taking
ferrous sulfate?
A. Take with milk
citrate
daily. What risk should the nurse discuss?
A. Hypertension
B. Hypernatremia
C. Electrolyte imbalance
D. Dehydration
Answer: C
Rationale: Chronic laxative use, especially osmotic types
like
magnesium citrate, causes fluid and electrolyte imbalances.
2. A client on sertraline reports increased restlessness
and
confusion. What should the nurse suspect?
A. Extrapyramidal symptoms
B. Lithium toxicity
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Answer: C
Rationale: Serotonin syndrome includes agitation,
confusion,
tachycardia, and hyperreflexia.
3. 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.
4. A client on sildenafil experiences chest pain during
intercourse. What is the nurse’s next action?
A. Administer nitroglycerin
B. Encourage rest and fluids
C. Call emergency services
D. Administer aspirin
Answer: C
Rationale: Sildenafil + nitrates can cause life-threatening
hypotension. Do not give nitro—call 911.
5. A client receiving amphotericin B develops chills and
fever.
What should the nurse do?
A. Stop the infusion
B. Document findings
C. Pre-medicate with acetaminophen
D. Increase infusion rate
Answer: C
Rationale: Infusion reactions are common. Premedication
with
acetaminophen or diphenhydramine is standard.
6. A client taking isoniazid (INH) for tuberculosis develops
numbness and tingling in their hands and feet. What should
the
nurse anticipate?
A. The need for increased calcium
B. Administration of pyridoxine (vitamin B6)
, C. Discontinuation of therapy
D. Addition of prednisone
Answer: B
Rationale: Isoniazid can cause peripheral neuropathy, often
prevented or treated with vitamin B6.
7. A nurse teaches a client taking cyclobenzaprine. Which
statement indicates understanding?
A. “I will take this long-term.”
B. “I can drink alcohol in moderation.”
C. “I should avoid driving until I know how it affects me.”
D. “It will help my heart condition.”
Answer: C
Rationale: Cyclobenzaprine causes drowsiness. Clients
should
avoid driving or alcohol initially.
8. A client receiving methotrexate for cancer reports
mouth
sores. What is the nurse's best response?
A. “This is a normal side effect.”
B. “Increase intake of spicy food.”
C. “Use a soft toothbrush and rinse with saline.”
D. “Chew gum frequently.”
Answer: C
Rationale: Mouth sores (stomatitis) are common. Gentle oral
care
is essential to prevent infection and discomfort.
9. What should the nurse include when teaching a client
taking
ferrous sulfate?
A. Take with milk
