Question 1

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?

Accepted Answer

Answer reason: With continuous suction, medications delivered into the stomach can be immediately removed before they have time to dissolve and be absorbed. Temporarily clamping the suction allows the medication to remain in the GI tract long enough to take effect. Flushing is important, but it should not replace holding suction; it is typically done before and after administration to maintain patency. Crushing tablets may be inappropriate for enteric-coated or extended-release forms and does not address the suction issue.
Category reason: This item tests a nursing action required for safe medication delivery via an NG tube connected to suction, which is a clinical medication-administration decision.

Question 2

The nurse is caring for a patient taking cimetidine (Tagamet) orally. Which should the nurse consider about administering this drug?

Accepted Answer

Answer reason: Giving oral cimetidine with food is commonly recommended to improve gastrointestinal tolerance and help align dosing with periods of acid secretion associated with eating. Administering it with meals also supports consistent absorption and reduces the likelihood of dyspepsia or nausea. The other timing choices are unnecessarily specific or not standard for this medication’s routine administration guidance.
Category reason: This question tests safe medication timing and how to administer an ordered drug, which is a nursing medication administration decision rather than foundational physiology.

Question 3

An 18 month old child was brought to the well-baby clinic for booster dose of DPT vaccine. Which among the following muscles is preferred by the nurse to administer vaccine?

Accepted Answer

Answer reason: For an 18-month-old, the anterolateral thigh provides a large, well-developed muscle mass with reliable absorption for intramuscular immunizations. It avoids the sciatic nerve injury risk associated with the dorsogluteal site and is generally preferred over gluteal sites in young children. The deltoid may be too small in many toddlers for larger-volume IM injections and can increase the chance of improper landmarking. Therefore the vastus lateralis is the safest, most recommended IM site in this age group.
Category reason: This question tests correct intramuscular injection site selection for a pediatric immunization, which is a nursing medication/vaccine administration skill under Pharmacological and Parenteral Therapies.

Question 4

Scenario: A patient with type 1 diabetes is to receive regular and NPH insulin. What is the correct procedure?

Accepted Answer

Answer reason: Drawing up the clear (regular) insulin before the cloudy (NPH) prevents contaminating the regular insulin vial with NPH, which could alter the onset and dosing accuracy. NPH is resuspended by gentle rolling rather than shaking to avoid bubbles and inaccurate measurement. Mixing them in one syringe is appropriate when ordered, using the correct sequence to maintain insulin purity and predictable pharmacokinetics.
Category reason: This question tests safe nursing technique for preparing and mixing insulins, which is a medication administration competency under Pharmacological and Parenteral Therapies.

Question 5

A nurse is preparing to administer a medication. What is the first step the nurse should take?

Accepted Answer

Answer reason: B) Verify the medication order Medication safety begins with confirming there is a valid, complete provider order before any further steps are taken. Verifying the order ensures the right medication, dose, route, time, and indication are appropriate and helps catch transcription or prescribing errors early. After the order is confirmed, the nurse can proceed with client identification, assessment for contraindications/allergies, and then preparation/administration using the rights of medication administration.
Category reason: This question tests the correct nursing sequence and safety steps for administering medications, which is a patient-care intervention under Medication Administration.

Question 6

When should a nurse perform a patient assessment?

Accepted Answer

Answer reason: B) Before administering medications A focused assessment before giving medications ensures the drug is indicated and safe at that moment by checking relevant vital signs, symptoms, allergies, and current clinical status. It helps detect contraindications or changes (e.g., low blood pressure before antihypertensives, low apical pulse before digoxin) that would require holding the dose and notifying the provider. This step reduces medication errors and prevents adverse drug events. While assessments also occur at other times, the pre-administration assessment is a consistent safety requirement tied directly to medication administration.
Category reason: This question tests nursing judgment about safe timing of patient assessment in relation to giving medications, which is a core Medication Administration safety concept.

Question 7

A nurse is teaching about warfarin. Which food should the patient be cautious about?

Accepted Answer

Answer reason: Vitamin K intake affects warfarin’s anticoagulant effect because warfarin inhibits vitamin K–dependent clotting factor activation. Leafy green vegetables are high in vitamin K and can reduce anticoagulation (lower INR) if intake increases, raising the risk of thrombosis. Patients should not necessarily avoid these foods but keep vitamin K intake consistent and have INR monitored with any major dietary changes. Among the options, spinach is the highest in vitamin K and is the key food to use caution with.
Category reason: This question tests patient education about a medication–food interaction that alters anticoagulant effectiveness, which is a nursing medication administration/teaching responsibility.

Question 8

Scenario: A patient with CHF has 3+ edema and crackles on auscultation. What is the nurse's best action?

Accepted Answer

Answer reason: Crackles and 3+ edema indicate fluid volume overload in congestive heart failure. A prescribed diuretic directly treats the underlying problem by promoting diuresis, reducing pulmonary congestion, and improving oxygenation/work of breathing. Encouraging fluids would worsen overload, and elevating the foot of the bed can increase venous return and potentially exacerbate pulmonary edema. Limiting activity may reduce oxygen demand but does not address the immediate excess fluid causing the respiratory findings.
Category reason: This is primarily a nursing intervention question requiring selection of the safest, most effective immediate action, centered on administering an ordered medication to manage a symptomatic condition.

Question 9

Scenario: A patient is on 5 L/min nasal cannula and complains of dry nasal passages. What should the nurse do?

Accepted Answer

Answer reason: Oxygen delivered by nasal cannula can dry the nasal mucosa, especially at higher flow rates, leading to irritation and discomfort. Humidification adds moisture to the delivered gas to reduce mucosal drying and improve tolerance while maintaining the prescribed oxygen therapy. Stopping oxygen or switching devices is unnecessary if the patient is otherwise stable, and increasing the flow would likely worsen dryness and may deliver an inappropriately higher oxygen dose.
Category reason: This is a nursing intervention question about managing oxygen therapy equipment to reduce an adverse effect and promote patient comfort while maintaining treatment, which aligns with NCLEX patient-care decision-making.

Question 10

Scenario: A patient 1 day post-op is afraid to get out of bed due to pain. What should the nurse do first?

Accepted Answer

Answer reason: Effective postoperative mobility requires adequate analgesia to improve participation, reduce anxiety, and prevent complications like atelectasis, DVT, and constipation. Giving ordered pain medication before ambulation is a safe, evidence-based first step that supports early mobilization while preventing unnecessary suffering. Options that ignore pain or delay activity increase risk for immobility-related complications and undermine recovery. A wheelchair may be supportive if needed, but addressing pain first is the priority to enable safe ambulation.
Category reason: This question tests the nurse’s initial intervention to support postoperative ambulation by administering analgesia, which is a patient-care decision centered on safe medication use before activity.

Question 11

Scenario: A 2-year-old child with a fever of 39.2°C is restless and crying. What is the priority nursing action?

Accepted Answer

Answer reason: For a febrile toddler, the safest priority is to reduce fever with an age-appropriate antipyretic while supporting hydration to prevent dehydration from increased insensible losses. Cold-water bathing and ice packs can trigger shivering and peripheral vasoconstriction, which may increase metabolic demand and make the child more uncomfortable. Wrapping in a blanket can worsen hyperthermia by trapping heat. Monitoring response and reassessing temperature and hydration status after intervention are key.
Category reason: This question asks for the priority nursing intervention for a symptomatic febrile child, focusing on safe medication use and supportive care decisions, which aligns with NCLEX patient-care judgment under medication administration.

Question 12

A nurse prepares to administer the first dose of captopril. What is the priority assessment?

Accepted Answer

Answer reason: C. Blood pressure ACE inhibitors like captopril can cause significant first-dose hypotension, especially in patients who are volume depleted or taking diuretics. Assessing baseline blood pressure helps determine whether it is safe to give the medication and provides a comparison for post-dose monitoring. Detecting hypotension early reduces risk of syncope, falls, and decreased organ perfusion.
Category reason: This question tests a nursing priority assessment required for safe administration of a prescribed medication and monitoring for expected adverse effects, which fits Medication Administration.

Question 13

A nurse is preparing to administer digoxin. Which assessment is most important before giving the drug?

Accepted Answer

Answer reason: Digoxin can cause bradycardia and other dysrhythmias due to its effects on AV node conduction and increased vagal tone. Assessing the apical pulse for a full minute best detects a slow or irregular rhythm that would warrant holding the dose and notifying the provider (commonly if

Question 14

The nurse is providing education to a client who is undergoing tuberculosis (TB) treatment. Which of the following statements would be inappropriate to include in the teaching?

Accepted Answer

Answer reason: This advice is not a standard component of TB treatment teaching and does not address transmission prevention, medication safety, or adherence. Key education focuses on taking anti-TB medications correctly, recognizing significant adverse effects (e.g., hepatotoxicity), and reducing spread via respiratory hygiene. The other statements align with common TB medication or infection-control counseling for clients receiving TB therapy.
Category reason: This question tests client teaching related to TB pharmacotherapy and appropriate medication/infection-control instructions, which is a nursing care decision under Medication Administration.

Question 15

Which action should the nurse take before administering atenolol to a client?

Accepted Answer

Answer reason: Atenolol is a beta-1 selective blocker that lowers heart rate and blood pressure, so baseline vital signs are essential to prevent administering it when the client is hypotensive or bradycardic. Nursing practice commonly includes holding and notifying the provider if the pulse is below an ordered threshold (often

Question 16

Scenario: A nurse is educating a patient scheduled for surgery tomorrow about post-op care. What statement by the patient indicates understanding?

Accepted Answer

Answer reason: B) “I will press the PCA button before getting up.” Using patient-controlled analgesia proactively helps achieve adequate pain control before activity, which supports early ambulation and deep breathing. Better pain management reduces postoperative complications such as atelectasis and venous thromboembolism by enabling mobility. The other statements reflect unsafe misconceptions: prolonged bedrest and minimizing movement increase complication risk, and ambulation should be supervised initially regardless of dizziness due to fall risk and orthostatic hypotension.
Category reason: This item tests safe postoperative nursing teaching about appropriate use of PCA in relation to mobility and pain control, which is a medication administration competency in patient care.

Question 17

The nurse is preparing to administer adenosine to a patient with SVT. What is the correct method?

Accepted Answer

Answer reason: Adenosine has an extremely short half-life (seconds), so it must reach the heart quickly to terminate AV nodal reentry SVT. Therefore it is administered as a rapid IV bolus through a large/proximal vein, immediately followed by a normal saline flush to ensure rapid delivery into central circulation. Slow infusion, IM, or oral administration would not achieve the necessary rapid onset and would be ineffective. Continuous ECG monitoring is used because transient arrhythmias or brief asystole can occur.
Category reason: This question tests the correct nursing technique for administering a specific IV antiarrhythmic medication, which is a patient-care medication administration decision rather than foundational science.

Question 18

The nurse is administering prednisone. Which instruction is most important?

Accepted Answer

Answer reason: Prednisone (a corticosteroid) commonly causes gastrointestinal irritation and can increase the risk of gastritis or peptic ulcer symptoms, so taking it with food helps minimize discomfort and irritation. Patients should not stop corticosteroids abruptly because this can precipitate adrenal insufficiency after suppression of the hypothalamic-pituitary-adrenal axis. Grapefruit juice is not a standard key interaction taught for prednisone in routine nursing administration teaching. Avoiding dairy is not a relevant or evidence-based priority instruction for prednisone.
Category reason: This is primarily about safe nursing medication teaching and administration considerations for a prescribed corticosteroid, which aligns with Medication Administration under Pharmacological and Parenteral Therapies.

Question 19

Scenario: A newly diagnosed diabetic is learning insulin self-injection. Q. Which statement indicates correct understanding?

Accepted Answer

Answer reason: Rotating subcutaneous insulin injection sites within the same general area helps ensure more consistent absorption and prevents lipohypertrophy/lipoatrophy, which can cause erratic glucose control. Injecting in the exact same spot daily increases local tissue changes and absorption variability. Massaging after injection can speed absorption unpredictably and may increase bruising. Insulin pens should be stored per manufacturer guidance (typically refrigerated before first use, then room temperature after opening); freezing can denature insulin and make it ineffective.
Category reason: This question tests safe patient teaching and technique for administering subcutaneous insulin, which is a nursing medication-administration competency.

Question 20

A client is taking lisinopril (Zestril) and furosemide (Lasix) together. What should the nurse do?

Accepted Answer

Answer reason: Lisinopril (an ACE inhibitor) and furosemide (a loop diuretic) are commonly prescribed together to manage hypertension and heart failure by reducing fluid volume and lowering afterload. This combination is not inherently contraindicated, so routine administration is appropriate when ordered. The nurse should still monitor for hypotension (especially first-dose/volume depletion), renal function changes, and potassium abnormalities (ACE inhibitors can raise potassium while loop diuretics can lower it).
Category reason: This question tests a nursing action regarding whether to give ordered medications and how to respond to a common drug combination, fitting Medication Administration within Pharmacological and Parenteral Therapies.

Question 21

A nurse is teaching a patient about levothyroxine. Which statement indicates a need for further teaching?

Accepted Answer

Answer reason: A. “I can take this medication at bedtime.” Levothyroxine should be taken consistently in the morning on an empty stomach (typically 30–60 minutes before breakfast) to optimize absorption; taking it at bedtime can decrease or vary absorption depending on recent food, supplements, and other meds. Consistency of timing and avoiding interactions (e.g., calcium, iron, antacids, and some high-fiber foods) are key to maintaining stable thyroid hormone levels. Not skipping doses supports steady therapeutic effect, and improved energy is expected gradually as hypothyroid symptoms resolve.
Category reason: This is a patient-teaching question about correct administration timing and adherence for a medication, which is nursing judgment in safe medication administration.

Question 22

Which behavior shows understanding of iron supplementation?

Accepted Answer

Answer reason: h." Iron is best absorbed in an acidic environment, so taking it without food generally improves absorption. Milk and antacids can decrease absorption by raising gastric pH or binding iron, making them poor choices to take at the same time. Constipation is a common side effect; clients should be taught management strategies (e.g., fluids, fiber, stool softener if prescribed) rather than stopping the medication.
Category reason: This question tests correct client teaching about how to take a medication and interactions that affect absorption, which aligns with Medication Administration.

Question 23

A patient with a history of DVT is prescribed enoxaparin. What is the correct nursing action during administration?

Accepted Answer

Answer reason: C. Inject into the abdomen, avoiding the umbilical area Enoxaparin is administered subcutaneously, and the preferred sites are the anterolateral/posterolateral abdominal areas at least about 2 inches from the umbilicus to reduce local complications. The injection should not be aspirated and the site should not be massaged because these actions increase tissue trauma and bruising/hematoma risk. Intramuscular administration is contraindicated due to bleeding risk with anticoagulants. Proper technique helps minimize adverse effects while ensuring therapeutic anticoagulation.
Category reason: This question tests safe nursing technique for administering an anticoagulant injection (route, site, and actions to avoid), which is a medication administration competency.

Question 24

Scenario: A patient is prescribed enoxaparin for DVT prevention. Q. What is the correct nursing action during administration?

Accepted Answer

Answer reason: Enoxaparin is administered subcutaneously, and the preferred sites are the anterolateral or posterolateral abdominal wall. The injection should be given at least about 2 inches (5 cm) away from the umbilicus and rotated to reduce bruising and tissue irritation. Aspirating and massaging increase local tissue trauma and bruising/hematoma risk, and intramuscular administration is contraindicated due to bleeding risk.
Category reason: This question tests safe technique for administering a prescribed anticoagulant (route, site selection, and avoidance of actions that increase bleeding), which is a nursing medication administration competency.

Question 25

A client with rheumatoid arthritis is prescribed methotrexate. Which instruction is most important?

Accepted Answer

Answer reason: Methotrexate inhibits folate metabolism and can cause folate-deficiency–related adverse effects such as stomatitis, gastrointestinal intolerance, and bone marrow suppression. Routine folic acid supplementation reduces these toxicities and improves tolerability without significantly reducing efficacy when used as prescribed for rheumatoid arthritis. The other instructions are not universally essential for safety and may mislead the client into inappropriate self-management of disease activity.
Category reason: This question tests nursing teaching about safe medication use and minimizing adverse effects of a prescribed drug, which fits Medication Administration within Pharmacological and Parenteral Therapies.

Question 26

A breastfeeding mother asks if she can take ibuprofen for postpartum pain. What is the best response?

Accepted Answer

Answer reason: A) “Ibuprofen is safe for breastfeeding.” Ibuprofen is considered compatible with breastfeeding because it transfers into breast milk in very small amounts and has a short half-life, making infant exposure minimal. It is commonly recommended for postpartum pain and inflammation and is generally preferred over many other NSAIDs in lactation. Advising to stop breastfeeding or restrict to only acetaminophen is unnecessarily limiting and not evidence-based for typical dosing. Decreased milk supply is more associated with estrogen-containing contraceptives and certain decongestants rather than ibuprofen.
Category reason: This is a patient-care medication counseling question about safe analgesic use during breastfeeding, which fits NCLEX medication administration and teaching responsibilities.

Question 27

Scenario: A post-op patient complains of severe pain but is reluctant to use the PCA button? Q. What is the nurse's best response?

Accepted Answer

Answer reason: n." PCA is intended to allow the patient to self-administer prescribed analgesia promptly when pain occurs, which improves pain control and can reduce anxiety about dosing. Teaching that the device is safe and patient-controlled supports adherence while reinforcing a key safety principle: only the patient should activate the button. Having family press the button is unsafe (risk of oversedation/respiratory depression), and requiring nurse presence or pressing on a schedule undermines appropriate, individualized pain relief.
Category reason: This question tests nursing teaching and safe use of patient-controlled analgesia, which is part of medication administration responsibilities and patient safety in pharmacologic therapy.

Question 28

A way to the following reason should a nurse in shark declined to avoid taking guaifenesin with combination over the counter cold products?

Accepted Answer

Answer reason: Many combination OTC cold products include overlapping active ingredients, creating a high risk of unintentional therapeutic duplication and potential adverse effects. This teaching is a medication-safety intervention: checking labels prevents exceeding recommended doses when a client already takes a single-ingredient expectorant. The correct choice directly explains why combining these products is unsafe—both may contain the same expectorant. Rebound congestion is associated with topical nasal decongestant overuse (e.g., oxymetazoline), not guaifenesin, and tolerance is not a typical concern with this expectorant.

Question 29

The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instructions should be given to the client?

Accepted Answer

Answer reason: C. Take medication with water only Alendronate is an oral bisphosphonate that can cause significant esophageal irritation and has markedly reduced absorption when taken with anything other than plain water. Clients should take it first thing in the morning with a full glass of water and avoid food, beverages, and other drugs for at least 30 minutes to maximize absorption. They must remain upright (sitting/standing) for at least 30 minutes rather than resting in bed to reduce reflux and esophagitis risk. While spacing from other medications is relevant, the key instruction among the choices is using only water; the “1 hour” interval is not the standard minimum teaching.

Question 30

A nurse is preparing to administer regular insulin to a child who has type 1 diabetes mellitus. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Insulin that is too cold can increase injection discomfort and may slow absorption from subcutaneous tissue, so allowing it to reach room temperature is appropriate. Subcutaneous insulin is typically given with a small-gauge needle (e.g., 25–31 gauge), making a 21-gauge needle unnecessarily large and more painful. A 15° angle is used for intradermal injections; subcutaneous insulin is usually administered at 45–90° depending on tissue thickness. The medial forearm is not a recommended site for routine subcutaneous insulin administration; preferred sites include abdomen, thigh, upper arm, and buttocks with rotation.

Question 31

Commonest site used for the IM Injection infant is ?

Accepted Answer

Answer reason: The anterolateral thigh (vastus lateralis) is the preferred and most commonly used site because it has adequate muscle mass from birth and provides reliable medication absorption. In contrast, the gluteal region is avoided in infants due to small muscle mass and higher risk of sciatic nerve injury. The deltoid is generally reserved for older children when sufficient muscle develops, and biceps is not a standard IM site for infants.

Question 32

An adult client is to receive heparin sodium (Heparin) 5,000 units subcutaneously. Which of the following techniques should be used by the nurse to administer the medication?

Accepted Answer

Answer reason: Subcutaneous heparin is an anticoagulant, so minimizing tissue trauma is essential to reduce bleeding and hematoma formation. Aspiration and unnecessary manipulation can increase local tissue injury and capillary disruption, raising the risk of bruising. The correct technique is to inject subcutaneously (typically abdomen), avoid aspiration, and avoid post-injection rubbing. Massaging the site is a common error because it further promotes bleeding into the tissue, and an 18–20 gauge 1-inch needle is inappropriate for subcutaneous injections.

Question 33

The nurse is preparing to administer digoxin to an adult client. The apical heart rate is 54 bpm. What is the nurse's next action?

Accepted Answer

Answer reason: In adults, the nurse should withhold digoxin when the apical pulse is below 60 bpm and then contact the provider for further instructions and evaluation (including possible toxicity or need for dose adjustment). Administering despite a pulse of 54 bpm increases risk of worsening bradycardia, hypotension, and dysrhythmias. Simply rechecking later delays necessary action, and independently giving a partial dose is outside typical nursing scope without an order and does not address the safety concern.

Question 34

Before administering morphine to a client, the nurse should assess the client?

Accepted Answer

Answer reason: Assessing baseline respirations identifies clients at higher risk (e.g., low rate or shallow breathing) and provides a clear hold parameter if respirations are already inadequate. While blood pressure and pulse can drop with opioids, these changes are generally less immediately fatal than respiratory depression and are monitored after administration as well. If respirations are below facility threshold (often

Question 35

A nurse administers 12 units lispro insulin at 0700 to a client. Within which time frame must the morning meal be served?

Accepted Answer

Answer reason: Serving the meal within this window aligns food absorption with insulin activity as glucose begins to drop. Waiting longer increases the mismatch between insulin effect and available circulating glucose, raising hypoglycemia risk. Longer time frames such as 45–60 minutes are more consistent with shorter-acting (regular) insulin timing rather than lispro.

Question 36

A nurse is preparing to give digoxin to a pediatric client. The apical heart rate is 78 bpm. What is the nurse's next action?

Accepted Answer

Answer reason:  Digoxin can cause clinically significant bradycardia, so safe administration requires assessing the apical pulse and withholding the medication if the heart rate is below the age-appropriate threshold. In pediatric clients, a common hold parameter is an apical rate

Question 37

A nurse is caring for a client who has been diagnosed with Addison’s disease. Which of the following interventions should the nurse prioritize?

Accepted Answer

Answer reason: Addison’s disease is adrenal insufficiency, creating a life-threatening deficit of cortisol (and often aldosterone) that can rapidly progress to hypotension, shock, and hypoglycemia if not treated. Priority nursing care is to replace the missing glucocorticoid to stabilize hemodynamics and support the stress response. Administering the ordered steroid is a time-sensitive, definitive intervention that prevents adrenal crisis and improves symptoms such as weakness and fatigue. Monitoring intake/output and assessing skin are supportive measures but do not correct the underlying hormone deficiency. Rest periods may help fatigue but is not as urgent or physiologically protective as steroid replacement.

Question 38

A nurse is teaching a client received a prescription for interferon beta-1a for the treatment of multiple sclerosis. Which the following information should the nurse include?

Accepted Answer

Answer reason: The thigh and upper arm are common recommended injection sites for self-administration, making this instruction directly relevant to safe medication technique. Muscle aches/flu-like symptoms are expected adverse effects and are managed with supportive measures rather than taking additional doses, which could increase toxicity. Routine monthly kidney function testing is not the key monitoring focus compared with liver function tests and CBC, and reconstituted product handling/storage should follow specific labeling rather than a general “room temperature after mixing” instruction.

Question 39

A nurse is preparing to administer digoxin to a client who suffers from heart failure. What must the nurse consider before administering this medication?

Accepted Answer

Answer reason: The nurse should assess the apical pulse for a full minute before giving the dose and hold the medication and notify the provider if the pulse is below the facility parameter (commonly

Question 40

A client with post-traumatic stress disorder has just been prescribed sertraline. When teaching the client about this medication, which information would the nurse most likely stress?

Accepted Answer

Answer reason: Teaching should emphasize taking it at the same time each day and continuing it as prescribed because symptom improvement may take several weeks. Appetite changes can occur but are not usually an urgent danger sign requiring immediate medical assistance unless severe or accompanied by other concerning symptoms. SSRIs are not given sublingually, and they do not require strict timing around meals; they are generally taken with or without food based on tolerability.

Question 41

A nurse is preparing to administer a rectal suppository to a client. After applying gloves, checking the client's identification band, and closing the door, what is the next step of the nurse?

Accepted Answer

Answer reason: Lubrication reduces mucosal trauma and helps the suppository pass through the anal sphincter without unnecessary discomfort, which supports correct administration and retention. Trendelenburg is not the recommended position; the left lateral (Sims) position is typically used to follow rectal anatomy and promote comfort. Hand hygiene occurs after completing the procedure and removing gloves, and documentation is done after administration rather than before.

Question 42

Which of the following interventions should the nurse consider when giving an oral medication to a child?

Accepted Answer

Answer reason: Re-administering what is pushed out helps achieve the prescribed therapeutic dose when loss is clearly observed and the medication remains available to give again safely. Mixing drugs with milk or favorite foods can create unpredictable intake (the child may not finish) and may also affect absorption or cause aversion to that food. Diluting a dose in a full glass increases the risk that the child will not consume the entire amount, resulting in underdosing.

Question 43

The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription?

Accepted Answer

Answer reason: A 10 mg nightly dose is above typical maximum dosing and is not an appropriate starting dose, making it the clearest prescription to question for safety. Non-benzodiazepine and melatonin-receptor agents are generally preferred at the lowest effective dose, whereas higher hypnotic doses markedly increase fall risk. In contrast, melatonin-receptor therapy is not associated with respiratory depression or significant cognitive impairment to the same extent, and other hypnotics can be acceptable if ordered at geriatric-appropriate doses and monitored.

Question 44

Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)?

Accepted Answer

Answer reason: Morning administration also reduces fall risk from frequent nighttime toileting, especially in older adults. Spironolactone is potassium-sparing, so increasing high-potassium foods raises the risk of hyperkalemia and is unsafe. Although gynecomastia can occur with spironolactone, it is generally a non-urgent adverse effect to report at follow-up unless severe or distressing, so it is not the best primary teaching point compared with safe dosing timing.

Question 45

Twenty minutes after the nurse starts a secondary IV infusion of cefepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement?

Accepted Answer

Answer reason: In the absence of red-flag findings (e.g., rash/urticaria, wheezing/bronchospasm, facial or airway swelling, hypotension, chest or back pain), the priority is symptom management while completing the ordered antimicrobial therapy. Administering a prescribed PRN antiemetic addresses comfort and helps the client tolerate the infusion without unnecessarily interrupting treatment. Stopping the infusion and notifying the provider is more appropriate when there are signs of a serious reaction or clinical instability. Increasing the rate would risk worsening intolerance and adverse effects and is not a safe response to nausea.

Question 46

An 8-year-old boy is evaluated and diagnosed with absence seizures. He is started on ethosuximide (Zarontin). Which information should the nurse provide the parents?

Accepted Answer

Answer reason: Ethosuximide is a first-line medication for absence seizures, and pediatric teaching emphasizes monitoring for adverse effects that can impact nutrition and development. This drug can cause significant gastrointestinal upset (nausea, vomiting, anorexia), which may reduce intake and contribute to poor weight gain over time. Tracking height and weight helps detect early growth deviation so the prescriber can adjust the regimen, dosing, or supportive measures. In contrast, routine restriction of sports is not standard for well-controlled absence seizures; safety precautions are individualized rather than blanket activity prohibition. Hydration is generally healthy but is not the key medication-specific monitoring priority being tested here.

Question 47

A client admitted with hepatitis B is prescribed hydrocodone with acetaminophen (Vicodin) 2 tablets for the nurse to administer. What is the most appropriate action for the nurse to take?

Accepted Answer

Answer reason: The key principle is that acetaminophen is hepatically metabolized and can worsen liver injury, so clients with active hepatitis are at increased risk for toxicity when standard combination doses are used. Two tablets of hydrocodone/acetaminophen may deliver a clinically significant acetaminophen load depending on the formulation, and safe dosing should be explicitly verified or adjusted for hepatic impairment. The safest nursing action is to clarify the prescription and dosing limits with the prescriber rather than independently changing the dose. Administering as ordered risks harm, while giving only one tablet is an unauthorized dose change and holding the medication without clarification may unnecessarily delay pain control.

Question 48

What nursing action is indicated for a patient on the first post op day of a female patient who had below the knee amputation complaining of pain in the affected limb?

Accepted Answer

Answer reason:  Phantom limb pain is a real neuropathic pain phenomenon caused by nervous system changes after amputation, so it must be acknowledged and treated as legitimate pain. On the first postoperative day, prompt analgesia is appropriate to support comfort, mobility, and pulmonary hygiene, and it also reduces stress responses that can impair recovery. Providing a brief explanation normalizes the experience and reduces anxiety, which can otherwise amplify pain perception. Giving a placebo is unethical and unsafe, and unwrapping a fresh surgical dressing risks contamination/bleeding and is not a first-line response to reported pain without an assessment indicating a pressure complication.

Question 49

A patient needs an intradermal injection for mantoux test, but he currently has bilateral forearm casts in place. Which at the following would be the best alternate site?

Accepted Answer

Answer reason: When the standard Mantoux site (volar forearm) is inaccessible due to casts, the lateral upper arm is an acceptable alternative intradermal site because the dermis is accessible and the area can be properly stabilized. The antecubital space is avoided because it involves a flexion crease with more movement and vascular structures, increasing risk of improper depth and inconsistent results. Abdomen and medial upper thigh are more typical for subcutaneous injections and are not preferred for Mantoux testing reliability.

Question 50

Which instruction should be given to a client taking Lugol’s solution prior to a thyroidectomy?

Accepted Answer

Answer reason: Mixing the dose with juice (or another flavored liquid) and taking it diluted helps improve palatability and decreases stomach upset, which supports adherence in the short pre-op course. Bedtime dosing is not a key administration requirement for iodine solutions, and photosensitivity precautions are not typical for this medication. Appetite changes are not the priority teaching compared with minimizing irritation and ensuring the dose is tolerated and taken correctly.

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