Question 1

Which of the following would be a priority component of the teaching plan for a client prescribed phenelzine (Nardil) for treatment of depression?

Accepted Answer

Answer reason: Phenelzine is a monoamine oxidase inhibitor (MAOI), so patient education must prioritize preventing hypertensive crisis from tyramine-containing foods and dangerous drug interactions (especially sympathomimetics in OTC cold products). Teaching to read food and OTC labels directly targets the highest-risk, preventable complication and supports safe self-management. Advising that headaches can be managed with OTC products is unsafe because headache may signal hypertensive crisis and many OTC agents can interact. The hyperglycemia teaching is not characteristic for MAOIs, and while orthostatic hypotension can occur, it is typically not the most life-threatening teaching point compared with tyramine/drug interaction precautions.

Question 2

A male client reports to the nurse that he is experiencing GI distress from high dose of corticosteroid and is planning to stop taking the medication. In response to the clients statement what nursing action is most important for the nurse to take?

Accepted Answer

Answer reason: High-dose systemic corticosteroids suppress the hypothalamic-pituitary-adrenal (HPA) axis, so abrupt discontinuation can precipitate acute adrenal insufficiency with potentially life-threatening hypotension, weakness, and shock. The immediate priority is safety teaching to prevent sudden withdrawal and to emphasize tapering per prescriber direction. While taking the drug with food may reduce GI upset, it does not address the highest-risk consequence of the client’s plan to stop suddenly. Assessing for other adverse effects and verifying dosing are appropriate, but they are secondary to preventing a dangerous medication-related complication.

Question 3

A 17-year-old client has been prescribed escitalopram (Lexapro) for increasing anxiety uncontrolled by other treatment measures. Because of the client's age, the nurse will ensure that the client and parents are taught what important information?

Accepted Answer

Answer reason: Adolescents and young adults taking SSRIs have an increased risk of suicidal ideation/behavior, particularly early in treatment or with dose changes, so prompt reporting of mood worsening is a key safety teaching point. This warning is especially emphasized for clients under 25 and requires close monitoring by family/caregivers. Escitalopram can also cause activation symptoms (e.g., agitation, insomnia), which may precede self-harm risk and should trigger urgent clinical contact. The other options are not core, high-priority age-specific safety counseling points for escitalopram and may misrepresent typical effects or needed accommodations.

Question 4

Older adult clients taking bethanechol (Urecholine) need to be assessed more frequently because of which of the following adverse effects?

Accepted Answer

Answer reason: Older adults are particularly vulnerable to orthostatic hypotension and related symptoms due to reduced baroreceptor responsiveness and higher baseline fall risk. This makes monitoring for lightheadedness and falls clinically important when initiating or adjusting therapy. In contrast, tachycardia and hypertension are not typical muscarinic adverse effects, and urinary retention is the condition the medication is used to treat rather than an expected adverse effect.

Question 5

A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The client's last blood pressure measurement was 78/36. What action should the nurse implement?

Accepted Answer

Answer reason: The safest nursing action within scope is to decrease the infusion to improve perfusion while continuing close hemodynamic monitoring. Simply increasing the frequency of blood pressure checks does not treat the life-threatening hypotension. Starting a vasopressor may be needed if hypotension persists, but first-line management is correcting the medication causing the adverse effect per titration parameters.

Question 6

An elderly post-operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone?

Accepted Answer

Answer reason: A respiratory rate of 7/min in an elderly postoperative patient on PCA strongly suggests opioid-induced respiratory depression requiring immediate reversal and supportive airway/breathing interventions. Subjective dyspnea without objective hypoventilation can have many causes and is not as specific for opioid toxicity. Wheezing/retractions point more toward bronchospasm or airway obstruction, and an SpO2 of 89% may improve with oxygen and ventilation support but does not specifically identify opioid effect as clearly as severe bradypnea.

Question 7

The nurse is providing education for a 12-year-old client with partial seizures currently prescribed valproic acid (Depakene). The nurse will teach the client and the parents to immediately report which symptom?

Accepted Answer

Answer reason: New or worsening abdominal pain (often with nausea/vomiting) is a red-flag sign consistent with pancreatitis and should be reported immediately. Prompt reporting allows rapid discontinuation and assessment (e.g., amylase/lipase, liver enzymes) to prevent progression to shock or organ failure. The other listed symptoms are not as specifically linked to these high-acuity adverse effects and are less likely to require emergent action compared with abdominal pain.

Question 8

Client returns to clinic after being started with captopril 3 weeks ago. What symptom during the assessment would be of priority concern?

Accepted Answer

Answer reason: A key safety principle with ACE inhibitors like captopril is to recognize rare but life-threatening blood dyscrasias, particularly neutropenia/agranulocytosis, which can present with infection signs. A high fever indicates possible serious infection in an immunocompromised state and warrants urgent evaluation (CBC with differential) and possible drug discontinuation. By contrast, a dry hacking cough is a common, usually non-emergent ACE-inhibitor effect related to bradykinin. Rash may occur but is generally less immediately dangerous unless accompanied by systemic allergic features, and tachycardia is nonspecific without other instability findings.

Question 9

A nurse is caring for a client with chronic heart failure who has been prescribed furosemide (Lasix) 40 mg IV push daily. Which of the following lab values should the nurse assess before administering the medication?

Accepted Answer

Answer reason: Giving IV furosemide when potassium is low raises the risk of dysrhythmias, especially in a heart-failure patient who may also be on digoxin or other cardioactive drugs. Checking these electrolytes directly addresses the most immediate, high-risk adverse effects that can be prevented by holding the dose and/or replacing electrolytes. Renal function tests are also relevant for ongoing monitoring, but electrolyte derangements are the most time-sensitive pre-administration safety concern for this medication.

Question 10

The nurse is caring for a child with nephrotic syndrome who is being treated with prednisone. The nurse is aware that which of the following is a complication of this medication?

Accepted Answer

Answer reason: Children receiving prednisone should be monitored for fever and other subtle signs of infection and taught to avoid exposure to contagious illnesses. A common distractor is hypoglycemia; glucocorticoids more typically cause hyperglycemia due to increased gluconeogenesis and insulin resistance. Hypotension is not an expected complication at therapeutic doses, and renal stones are not a classic primary adverse effect of prednisone compared with infection risk and metabolic effects.

Question 11

A 5-year-old is being treated for an acute attack of asthma using racemic epinephrine (epinephrine hydrochloride) nebulizer stat. Which finding indicates an adverse effect of this medication?

Accepted Answer

Answer reason: A marked tachycardia is a clinically important adverse effect because it signals excessive beta-1 activity and increases myocardial oxygen demand and risk of dysrhythmias. In a 5-year-old, a heart rate of 150 after treatment is concerning as a medication-related effect that warrants reassessment and possible dose/therapy adjustment. Tremor and excitability can occur with adrenergic bronchodilators but are generally less dangerous than significant tachycardia. Nausea is nonspecific and not the priority adverse effect to identify in this context.

Question 12

The nurse is caring for a client who is prescribed enoxaparin. Which laboratory value should the nurse monitor?

Accepted Answer

Answer reason:  Enoxaparin is a low–molecular-weight heparin, and a key safety risk is heparin-induced thrombocytopenia (HIT), which presents with a falling platelet count and paradoxical thrombosis. Therefore, monitoring platelet count helps detect this serious adverse effect early and guides stopping the drug and initiating alternative anticoagulation if needed. aPTT is primarily used to titrate unfractionated heparin, not routine LMWH dosing. INR is used to monitor warfarin therapy, and troponin monitors myocardial injury rather than anticoagulant safety.

Question 13

A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?

Accepted Answer

Answer reason: Protamine sulfate binds to heparin to form a stable inactive complex, making it the immediate antidote nurses should anticipate during IV heparin infusions. In contrast, aminocaproic acid is used mainly to inhibit fibrinolysis and is not the standard reversal for heparin toxicity. Prompt availability of the appropriate antidote supports rapid response to unexpected bleeding and improves patient safety.

Question 14

An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse?

Accepted Answer

Answer reason: Aspirin irreversibly inhibits platelet function, which can worsen ongoing hemarthrosis and prolong bleeding. Appropriate management focuses on replacing the missing clotting factor and protecting the affected joint to limit further hemorrhage. Pain control should preferentially use agents with minimal effects on platelet function (e.g., acetaminophen) rather than salicylates or most NSAIDs.

Question 15

The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

Accepted Answer

Answer reason: A baked potato is a classic high-potassium food choice that helps maintain potassium levels and reduces this risk. While fruits like bananas and oranges contain potassium, the baked potato typically provides a larger potassium load per serving, making it the best single answer. Patient education here targets preventing an adverse medication effect through appropriate diet selection.

Question 16

A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would the nurse anticipate finding on the initial assessment?

Accepted Answer

Answer reason: Low potassium increases myocardial sensitivity to digoxin, raising the risk of toxicity while also producing neuromuscular symptoms such as generalized weakness and muscle cramps. This finding fits the specific medication combination in the stem and is a high-yield early clue on assessment. Confusion can occur with toxicity but is less directly tied to the classic diuretic-induced electrolyte mechanism being tested here. Tinnitus is more characteristic of salicylate toxicity, and hematuria is not a typical digoxin effect.

Question 17

A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d. The client's family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect?

Accepted Answer

Answer reason: Sudden sustained upward deviation of the eyes is classic for an oculogyric crisis and typically occurs hours to days after starting or increasing the dose. This presentation is different from tardive dyskinesia, which is a late-onset syndrome with repetitive involuntary movements (often oral-facial) after chronic exposure. Clinically, the priority is to treat promptly with an anticholinergic such as benztropine or diphenhydramine and reassess the antipsychotic regimen.

Question 18

The provider orders Lanoxin (digoxin) 0.125 mg po and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?

Accepted Answer

Answer reason: The safest nursing teaching is to encourage consistent daily intake of potassium-rich foods to reduce hypokalemia risk while on furosemide. This directly supports medication safety because early toxicity can present with dysrhythmias, GI upset, and visual changes and may be precipitated by electrolyte disturbances. Among the listed choices, the potassium content is most clinically relevant for this drug combination. The other options are not reliably potassium-focused for daily reinforcement in the context of preventing this specific interaction.

Question 19

The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

Accepted Answer

Answer reason: Early toxicity can present with nonspecific systemic symptoms such as unusual weakness, lethargy, and fatigue, prompting review of serum digoxin level and contributing factors (e.g., hypokalemia). The other options are not typical indicators of digoxin toxicity: appetite changes more classically involve anorexia/nausea rather than increased appetite, and itching/constipation are not hallmark findings. Identifying subtle symptoms is important because progression can lead to dangerous dysrhythmias requiring urgent intervention.

Question 20

A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication?

Accepted Answer

Answer reason: With prolonged infusion, high doses, or renal impairment, thiocyanate can accumulate and cause toxicity (e.g., neurologic changes, tinnitus, confusion). Monitoring thiocyanate levels helps detect this specific medication-related toxicity risk early. The other listed labs may be relevant to the patient’s overall cardiopulmonary/renal status, but they do not directly track nitroprusside’s characteristic metabolite accumulation.

Question 21

Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?

Accepted Answer

Answer reason: Teaching focuses on preventing exaggerated sunburn and skin injury by avoiding strong sun exposure and using protective clothing/sunscreen. Tyramine restrictions are a key concern with MAO inhibitors, not typical antipsychotics, making that a classic distractor. The other food/drink options are not standard, high-yield avoidance teaching for this medication compared with the well-known photosensitivity risk.

Question 22

A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan?

Accepted Answer

Answer reason: Teaching commonly emphasizes avoiding alcohol because it can destabilize mood, reduce adherence, and complicate monitoring of adverse effects. In contrast, smoking cessation is generally beneficial but is not a key lithium-specific interaction taught as a primary safety point. Oral contraceptive “risk” counseling is not a standard lithium teaching priority compared with substance avoidance and safety precautions.

Question 23

The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?

Accepted Answer

Answer reason:  Combining serotonergic agents with MAO inhibitors is contraindicated because it can cause dangerously elevated serotonin levels and precipitate serotonin syndrome. The nurse should question this order and verify any current or recent MAOI use, including required washout periods before starting an SSRI. This interaction can lead to hyperthermia, autonomic instability, neuromuscular rigidity/clonus, and mental status changes, making it a high-priority safety concern. The other histories listed do not represent a major absolute contraindication to SSRI therapy in the way MAOI co-administration does.

Question 24

The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider?

Accepted Answer

Answer reason: An acute dystonic reaction (e.g., torticollis, oculogyric crisis, jaw/neck spasm, laryngospasm) is an urgent adverse effect because it can compromise the airway and requires prompt treatment (typically IM/IV anticholinergic such as benztropine or diphenhydramine) and provider notification. After months of therapy, any severe EPS still warrants immediate reporting due to potential progression and need for medication adjustment. The other options are not classic urgent, haloperidol-specific red flags compared with an acute dystonia presentation.

Question 25

The nurse admits a client with hypertension who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the most important information for the nurse to assess?

Accepted Answer

Answer reason: Establishing the client’s baseline pulse helps determine if the symptom is due to excessive rate slowing or an unsafe hemodynamic response requiring holding the drug, dose adjustment, or further evaluation. This is the most safety-critical assessment because significant bradycardia can progress to heart block or syncope. Potassium intake is more relevant to diuretics/RAAS inhibitors, and activity/rest patterns or dosing schedule are secondary once a potentially dangerous medication effect is suspected.

Question 26

What would the nurse expect to see in a client who is experiencing symptoms of tardive dyskinesia?

Accepted Answer

Answer reason: It presents with involuntary choreoathetoid movements, especially orofacial dyskinesias such as lip smacking, tongue protrusion, and chewing motions. Rapid, involuntary tongue movements directly match this hallmark presentation and are important to recognize early because symptoms can become irreversible. By contrast, hand tremors during meals are more typical of parkinsonism (another EPS) rather than tardive dyskinesia, and nonspecific behavioral changes do not describe a characteristic motor pattern.

Question 27

Although nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?

Accepted Answer

Answer reason: This bleeding may be subtle and present as occult blood loss, leading to anemia and positive stool guaiac without obvious hematemesis or melena initially. Nursing teaching commonly includes monitoring for black/tarry stools, epigastric pain, easy bruising, and reporting signs of blood loss, especially in older adults or those on anticoagulants. Constipation is more typical of opioids, and nystagmus or urinary incontinence are not expected common adverse effects of ibuprofen.

Question 28

A client is ordered warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse’s discharge instruction?

Accepted Answer

Answer reason: Epistaxis and gingival bleeding are common early warning signs that anticoagulation may be excessive and require evaluation and possible dose adjustment. This instruction is more critical than general lifestyle tips because it directly relates to preventing life-threatening hemorrhage. While consistent vitamin K intake and using a soft toothbrush are helpful, they are secondary to identifying and reporting active bleeding promptly. Patient safety hinges on knowing when to seek medical attention for bleeding symptoms.

Question 29

A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?

Accepted Answer

Answer reason: New fever and sore throat can be early indicators of neutropenia and impending severe infection, requiring prompt evaluation and a CBC. Teaching focuses on identifying red-flag adverse effects that need immediate provider contact rather than expected or less urgent effects. Endocrine effects like decreased libido or breast enlargement reflect hyperprolactinemia and are typically non-emergent compared with possible agranulocytosis.

Question 30

The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?

Accepted Answer

Answer reason: NSAIDs inhibit platelet aggregation and can irritate the gastric mucosa, creating an additive risk for serious GI bleeding when combined with anticoagulation. Many NSAIDs are readily available OTC (e.g., ibuprofen, naproxen), making this a key teaching point for safety. In contrast, guaifenesin and H2 blockers do not typically produce a clinically significant bleeding synergy with warfarin in routine use.

Question 31

A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?

Accepted Answer

Answer reason:  INH can cause peripheral neuropathy due to pyridoxine (vitamin B6) depletion, making new paresthesias a potentially serious adverse effect needing prompt evaluation and treatment. Reporting symptoms early allows dose adjustment and/or vitamin B6 supplementation to prevent progression to persistent nerve damage. Visual halos are more characteristic of ethambutol-related optic neuritis rather than INH toxicity. Photosensitivity is more typical of other medications and is not a classic urgent INH adverse effect compared with neuropathic symptoms.

Question 32

Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?

Accepted Answer

Answer reason: Periodic liver function tests help detect asymptomatic elevations in transaminases early, allowing timely dose adjustment or discontinuation before severe hepatitis develops. This is especially important in clients with additional risk factors (e.g., older age, alcohol use, underlying liver disease, pregnancy/postpartum). Kidney function, blood sugar, and cardiac enzymes are not the primary routine safety labs used to monitor INH toxicity.

Question 33

A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention?

Accepted Answer

Answer reason: Aminophylline (a methylxanthine) has a narrow therapeutic index and can cause CNS stimulation and cardiac dysrhythmias as early toxicity signs. Restlessness suggests stimulant effects, and palpitations raise concern for tachyarrhythmias, which is especially dangerous in a client with coronary artery disease due to increased myocardial oxygen demand and risk of ischemia. These findings warrant immediate assessment of vital signs/ECG and evaluation of serum theophylline level with prompt provider notification. Flushing/headache are more mild, and isolated increases in heart rate/BP are less specific than palpitations for impending dysrhythmia.

Question 34

The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. Which of these should be emphasized to the client to avoid?

Accepted Answer

Answer reason: Emphasizing avoidance (or at minimum, strict consistency) of high–vitamin K foods helps prevent subtherapeutic anticoagulation and reduces stroke risk in atrial fibrillation. Sunlight exposure and large gatherings do not directly alter warfarin’s anticoagulant action. Usual physical activity is generally encouraged, with caution to avoid trauma-risk activities because bleeding risk—not exercise itself—is the key concern.

Question 35

The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?

Accepted Answer

Answer reason: Aged cheeses and certain chocolate products are classic dietary triggers, so avoidance is a key safety precaution and a common test point. The other options do not address the major life-threatening risk specific to MAOIs. Teaching should also emphasize recognizing warning signs of hypertensive crisis (e.g., severe headache, palpitations) and seeking urgent care if they occur.

Question 36

A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?

Accepted Answer

Answer reason: In infants, a resting heart rate of 78 is abnormally low for age and is a more specific indicator of toxicity than nonspecific GI or neurobehavioral symptoms. Vomiting and irritability can occur with toxicity, but they are also common in many pediatric illnesses and may appear with therapeutic dosing. The potassium level shown is not elevated, so the clearest toxicity clue in this presentation is the unexpectedly low pulse.

Question 37

The nurse is teaching about nonsteroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?

Accepted Answer

Answer reason: Teaching clients to avoid taking the drug with food and to time dosing away from meals is intended to reduce these gastric side effects. Alcohol increases the risk of GI irritation and bleeding with NSAIDs, so advising “moderation” is unsafe rather than protective. Concurrent aspirin use also increases bleeding risk and should not be encouraged as an added analgesic with NSAIDs unless specifically prescribed.

Question 38

While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions?

Accepted Answer

Answer reason: Phenytoin commonly causes gingival hyperplasia, and meticulous oral hygiene with regular dental visits is the key preventive nursing teaching point. This education directly targets a predictable, clinically significant adverse effect that can lead to bleeding, infection, and poor nutrition if unmanaged. Families should also understand the medication must be taken consistently and not stopped just because seizures are controlled, making omission a dangerous choice. Promoting sleep with acetaminophen is not an indicated use, and a high-iron diet is not a priority teaching point specific to phenytoin therapy.

Question 39

The nurse is caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor?

Accepted Answer

Answer reason: Dopaminergic therapy can precipitate or worsen neuropsychiatric effects in Parkinson’s disease, including vivid dreams, confusion, and hallucinations, especially in older adults or with dose escalation. Levodopa increases central dopamine availability, which can exacerbate psychosis-like symptoms when dopaminergic tone becomes excessive. Anticholinergics like benztropine can also cause confusion, but classic medication-induced hallucinations in PD are strongly associated with dopaminergic agents used to treat motor symptoms. A key nursing action is to recognize this as a likely adverse effect and prompt provider reassessment of the antiparkinson regimen rather than assuming a primary psychiatric disorder.

Question 40

Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?

Accepted Answer

Answer reason: Monitoring helps detect hypotension early and prevents falls, syncope, and injury, especially after dose initiation or increases. Elevated blood pressure is not the typical class effect to monitor for routine safety compared with hypotension. Extrapyramidal symptoms may require antiparkinsonian medications, but blood pressure monitoring does not guide that decision.

Question 41

Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?

Accepted Answer

Answer reason: Alprazolam is a short-acting benzodiazepine, making rebound anxiety/insomnia particularly likely if it is stopped suddenly. Teaching should emphasize tapering as prescribed and monitoring for withdrawal manifestations rather than abruptly stopping the medication. A common distractor is assuming these agents provide pain relief; they are anxiolytic/sedative, not analgesic.

Question 42

The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention?

Accepted Answer

Answer reason: A glucose of 350 mg/dl represents a dangerous adverse effect requiring prompt intervention such as bedside recheck, provider notification, and insulin therapy per protocol. The other findings are not urgent in this context: 37.5°C is not a fever, urine output of 300 mL in 4 hours is adequate, and poor skin turgor suggests dehydration but is less immediately life-threatening than marked hyperglycemia during TPN initiation. Immediate action focuses on preventing acute metabolic complications and ensuring safe continuation of parenteral therapy.

Question 43

A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client?

Accepted Answer

Answer reason: After initiation and stabilization, ongoing periodic levels are a key safety teaching point because dehydration, renal function changes, and medication interactions can quickly raise levels. A low-sodium diet is unsafe because sodium depletion increases renal lithium reabsorption and can precipitate toxicity. Advising a diuretic is also dangerous, particularly thiazides, which commonly increase lithium concentrations; monitoring is the most broadly protective instruction here.

Question 44

A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?

Accepted Answer

Answer reason: This OTC product commonly contains aspirin, making it contraindicated unless specifically prescribed and monitored. Separating administration times does not mitigate the pharmacodynamic bleeding risk. Dose reduction is not a safe strategy because even small amounts can increase bleeding in an anticoagulated patient.

Question 45

A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

Accepted Answer

Answer reason: A blood pressure of 94/60 is low and metoprolol can further decrease blood pressure and cardiac output, increasing risk of dizziness, syncope, and poor perfusion. This finding warrants immediate provider notification to clarify parameters/hold order or adjust therapy before giving the new medication. The other values shown are within expected adult ranges and do not indicate imminent risk with administration in the same way.

Question 46

A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?

Accepted Answer

Answer reason: An allergic reaction would be more consistent with rash, hives, or respiratory symptoms rather than these predictable pharmacologic effects. Taking lithium on an empty stomach typically worsens nausea; it is commonly taken with food to reduce GI irritation. Reducing sodium and fluid intake increases lithium reabsorption in the kidneys and raises toxicity risk, which would be unsafe rather than symptom-minimizing.

Question 47

When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse?

Accepted Answer

Answer reason: Vomiting blood indicates an upper GI bleed, which can be rapid, occult until significant, and can quickly lead to hypovolemia and shock. In contrast, mild gum oozing or slightly blood-tinged urine can occur from minor mucosal bleeding and still warrants monitoring but is usually less emergent. This finding should prompt urgent assessment of hemodynamics, notification of the provider, and preparation to stop/reverse therapy and support circulation as ordered.

Question 48

To which of the following nursing home residents could the nurse safely administer tricyclic antidepressants without questioning the health care provider's order?

Accepted Answer

Answer reason: Tricyclic antidepressants have significant anticholinergic effects and can worsen conditions where anticholinergic-induced physiologic changes are dangerous. They can precipitate acute angle-closure in narrow-angle glaucoma by causing mydriasis, and they can cause urinary retention that may exacerbate benign prostatic hypertrophy. They also carry cardiac conduction/arrhythmia risk and orthostatic hypotension, making established coronary artery disease a higher-risk situation that warrants questioning/extra caution. Mild, well-controlled hypertension alone is not a classic absolute contraindication, so this resident is the safest choice among the options.

Question 49

Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective?

Accepted Answer

Answer reason: " Abrupt discontinuation of beta-blockers can cause rebound sympathetic stimulation with tachycardia, hypertension, and increased myocardial oxygen demand. This rebound effect can precipitate angina, dysrhythmias, or myocardial infarction, especially in clients with coronary artery disease risk. Effective teaching emphasizes tapering propranolol rather than stopping suddenly. The seizure statement is not a typical withdrawal risk for propranolol and reflects confusion with other medication classes.

Question 50

A client diagnosed with heart failure has a short run of ventricular tachycardia on the cardiac monitor one hour following intravenous furosemide. The nurse will anticipate which electrolyte replacement?

Accepted Answer

Answer reason: Hypokalemia increases myocardial irritability and predisposes to ventricular ectopy and ventricular tachycardia, so replacement is anticipated when new ventricular dysrhythmias occur after furosemide. While sodium may also be excreted, it is not the classic trigger for acute ventricular tachyarrhythmias in this context. Phosphorous and calcium abnormalities are less directly linked to immediate post–loop diuretic ventricular tachycardia than potassium depletion.

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