1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. A nurse is administering digoxin to a client. Which
finding
requires immediate action?
A. HR 62 bpm
B. Blurred vision with yellow halos
C. BP 140/88 mmHg
D. Urine output 400 mL in 8 hours
, Answer: B
Rationale: Visual disturbances and halos are signs of
digoxin
toxicity, especially when paired with bradycardia.
7. 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.
8. 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.
9. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
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.
2. 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.
3. 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.
4. 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.
5. 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.
6. A nurse is administering digoxin to a client. Which
finding
requires immediate action?
A. HR 62 bpm
B. Blurred vision with yellow halos
C. BP 140/88 mmHg
D. Urine output 400 mL in 8 hours
, Answer: B
Rationale: Visual disturbances and halos are signs of
digoxin
toxicity, especially when paired with bradycardia.
7. 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.
8. 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.
9. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
