Question 1

A client with atrial fibrillation is prescribed warfarin. Which finding should the nurse report immediately?

Accepted Answer

Answer reason: This suggests gastrointestinal bleeding (melena), a potentially life-threatening adverse effect of anticoagulation that requires immediate evaluation and possible reversal/holding of therapy. An INR of 2.0 is typically within the therapeutic range for atrial fibrillation and is not an emergency finding by itself. Minor bruising can occur with anticoagulants and is usually monitored unless it is excessive or accompanied by other bleeding. Loss of appetite is nonspecific and does not indicate acute bleeding or toxicity.
Category reason: This question tests recognition of a dangerous adverse effect of warfarin and the nursing action to promptly report it, which fits medication safety and adverse effects management.

Question 2

A client taking warfarin should be instructed to avoid which of the following?

Accepted Answer

Answer reason: Warfarin is an anticoagulant, and concomitant use of aspirin increases bleeding risk due to additive effects on hemostasis and aspirin’s antiplatelet action. This combination can lead to serious complications such as GI bleeding or intracranial hemorrhage unless specifically prescribed and closely monitored. Leafy green vegetables contain vitamin K and should be kept consistent rather than completely avoided, while bananas and water do not meaningfully increase bleeding risk.
Category reason: This question tests nursing medication safety teaching about drug–drug interactions and contraindications for warfarin, which fits Pharmacological and Parenteral Therapies—Adverse Effects-Contraindications.

Question 3

A nurse is reviewing ECG of a client receiving digoxin. Which finding requires intervention?

Accepted Answer

Answer reason: Digoxin increases myocardial excitability, and toxicity can present with new or worsening dysrhythmias, including premature ventricular contractions and more dangerous ventricular rhythms. A new onset of PVCs on ECG in a client taking digoxin is therefore an abnormal finding that warrants prompt assessment (e.g., symptoms, serum digoxin level, potassium/magnesium) and provider notification. By contrast, a PR interval of 0.20 sec can reflect digoxin’s expected AV nodal slowing, and an HR of 60 bpm may be acceptable if the client is stable and within ordered parameters. U waves are classically associated with hypokalemia, which is a risk factor for digoxin toxicity, but the most direct urgent ECG change listed indicating potential toxicity is new ventricular ectopy.
Category reason: This item asks the nurse to recognize an adverse ECG effect of a medication (digoxin) and determine which finding requires nursing intervention, aligning with monitoring for medication-related complications.

Question 4

Roles of nurse in psychiatric ward include all except:

Accepted Answer

Answer reason: C) If psychiatric symptoms subside, then sudden stop the drug Abruptly stopping antipsychotic medications can cause relapse of psychotic symptoms, withdrawal effects, and rebound phenomena; discontinuation should be planned and tapered under prescriber guidance. A nurse’s role includes monitoring for adverse effects, supporting medication adherence, and providing education about safe medication use. Advising avoidance of psychoactive substances is also appropriate because they can worsen symptoms and interfere with treatment.
Category reason: This item tests nursing responsibilities related to safe administration and patient education about psychotropic medications, including preventing harm from unsafe discontinuation, which fits Pharmacological and Parenteral Therapies.

Question 5

A client with hypertension is started on lisinopril. Which symptom is most concerning?

Accepted Answer

Answer reason: This finding suggests angioedema, a rare but life-threatening adverse effect of ACE inhibitors due to bradykinin accumulation. It can rapidly progress to airway obstruction, making it an emergency requiring immediate discontinuation of the drug and urgent evaluation/treatment. Dry cough and dizziness are common, usually non-emergent effects early in therapy, and headache is not a specific high-risk ACE-inhibitor reaction.
Category reason: This question tests recognition of a dangerous medication adverse effect and the need for urgent nursing action, which fits Pharmacological and Parenteral Therapies—Adverse Effects-Contraindications.

Question 6

Which finding in a patient on heparin therapy requires immediate attention?

Accepted Answer

Answer reason: B. Blood in urine Heparin increases bleeding risk, and hematuria indicates clinically significant internal bleeding that can rapidly worsen and requires prompt assessment and provider notification. This finding warrants holding further doses and evaluating coagulation status (e.g., aPTT/anti-Xa) and hemoglobin/hematocrit to determine severity. Mild bruising and injection-site discomfort are common expected effects, and a slight hemoglobin drop is concerning but less immediately specific than visible bleeding in the urine.
Category reason: This question tests nursing recognition of a dangerous adverse effect of an anticoagulant and the need for urgent intervention/notification, aligning with medication adverse effects management.

Question 7

A patient taking glipizide (Glucotrol) should be taught to avoid?

Accepted Answer

Answer reason: Alcohol can potentiate the hypoglycemic effects of sulfonylureas, increasing the risk of symptomatic low blood glucose. It may also impair hepatic gluconeogenesis and blunt a patient’s ability to recognize or appropriately respond to hypoglycemia. Additionally, some sulfonylureas can be associated with disulfiram-like reactions when combined with alcohol, so avoidance is a key safety teaching point.
Category reason: This question tests patient medication teaching and avoidance of a contraindicated substance to prevent an adverse drug effect, which falls under Pharmacological and Parenteral Therapies—Adverse Effects-Contraindications.

Question 8

A nurse is monitoring a client receiving IV heparin. Which finding indicates a complication?

Accepted Answer

Answer reason: Thrombocytopenia in a client receiving heparin is concerning for heparin-induced thrombocytopenia (HIT), a serious adverse drug reaction that increases risk of new thrombosis and bleeding complications. A platelet count below 150,000/mm3 or a significant drop from baseline warrants prompt evaluation and typically stopping heparin with initiation of a non-heparin anticoagulant if HIT is suspected. An aPTT of ~60 seconds may be within the therapeutic target range for many IV heparin protocols. INR is used to monitor warfarin, and mild bruising alone can occur with anticoagulants and is less specific than thrombocytopenia for a major complication.
Category reason: This question tests monitoring for and recognizing an adverse effect/contraindication of IV heparin therapy (HIT), which is a medication safety and complication-identification nursing judgment task.

Question 9

A client with chronic hypertension is receiving labetalol. Which finding would prompt the nurse to hold the medication?

Accepted Answer

Answer reason: Labetalol is a beta-blocker with alpha-blocking effects that can cause clinically significant bradycardia by decreasing SA node automaticity and AV node conduction. A heart rate in the mid-50s suggests excessive beta-blockade and increases risk for symptomatic hypotension, dizziness, syncope, or heart block, so the dose should be held and the prescriber notified per protocol. The elevated blood pressure indicates inadequate control rather than toxicity, and mild edema/proteinuria are not typical immediate hold parameters for this medication compared with low heart rate.
Category reason: This item tests nursing judgment about when to withhold an antihypertensive based on an adverse drug effect and safe medication administration parameters, which aligns with Pharmacological and Parenteral Therapies (Adverse Effects-Contraindications).

Question 10

Scenario: While receiving vancomycin IV, the patient develops flushing and itching on the neck and chest. Q. What is the nurse's next action?

Accepted Answer

Answer reason: This presentation is consistent with vancomycin infusion reaction ("red man syndrome"), a rate-related histamine release rather than an IgE-mediated anaphylaxis. The priority nursing intervention is to reduce the infusion rate (and often briefly pause if symptoms are significant) while assessing for progression to airway compromise, hypotension, or wheezing. Continued close monitoring and notifying the provider for further orders (e.g., antihistamine and future slower rate/premedication) is appropriate, but immediate provider notification or antihistamine administration is not the first step when symptoms are mild and rate-related.
Category reason: This question tests nursing recognition and immediate management of an IV medication adverse effect during administration, which falls under Pharmacological and Parenteral Therapies—Adverse Effects-Contraindications.

Question 11

A client with a DVT is receiving heparin. The nurse notes hematuria and bruising. What is the nurse's priority?

Accepted Answer

Answer reason: Hematuria and bruising indicate clinically significant bleeding from anticoagulation. The immediate nursing priority is to prevent further harm by stopping the anticoagulant and then promptly notifying the provider and anticipating labs (e.g., aPTT/anti-Xa, CBC) and possible reversal (protamine sulfate if ordered). Vitamin K reverses warfarin rather than heparin, and merely slowing the infusion delays definitive bleeding control. Dialysis is not an appropriate acute response to heparin-related bleeding.
Category reason: This item tests nursing recognition and immediate intervention for an adverse medication effect (bleeding) while administering IV heparin, which is a medication safety and management decision.

Question 12

Which finding is most concerning in a patient with severe preeclampsia on magnesium sulfate?

Accepted Answer

Answer reason: Magnesium sulfate toxicity can cause respiratory depression and is an urgent, potentially life-threatening adverse effect requiring immediate intervention (stop infusion, assess reflexes, prepare calcium gluconate). A respiratory rate of 10/min is below normal and indicates significant CNS/respiratory suppression. Drowsiness and mild nausea are common side effects at therapeutic levels. Urine output of 40 mL/hr is acceptable (≥30 mL/hr is typically desired) and supports ongoing magnesium clearance.
Category reason: This question tests recognition of a dangerous adverse effect of a high-alert medication (magnesium sulfate) and the need for prompt nursing action, which fits Pharmacological and Parenteral Therapies—Adverse Effects-Contraindications.

Question 13

A client receiving morphine IV reports shortness of breath and has a respiratory rate of 8/min. What is the nurse's next step?

Accepted Answer

Answer reason: C. Administer naloxone A respiratory rate of 8/min after IV morphine indicates clinically significant opioid-induced respiratory depression, which is an immediate life threat. The priority is to reverse the opioid effect promptly with an opioid antagonist to restore adequate ventilation. Oxygen alone does not correct hypoventilation and CO2 retention, and delaying for observation or a provider call risks rapid deterioration. Naloxone should be given while continuing to support airway and breathing and monitoring for recurrent sedation due to naloxone’s shorter duration than many opioids.
Category reason: This item tests recognition and immediate nursing intervention for a serious adverse effect of an opioid medication (respiratory depression) and the appropriate antidote, aligning with pharmacologic therapy adverse effects/contraindications.

Question 14

A client with atrial fibrillation is on warfarin. Which meal choice indicates a need for more teaching?

Accepted Answer

Answer reason: Warfarin’s anticoagulant effect is reduced by high vitamin K intake because vitamin K promotes synthesis of clotting factors. Spinach is vitamin K–rich, so choosing it suggests the client may not understand the need to keep vitamin K intake consistent. Green tea can also contain vitamin K and may further decrease anticoagulation, raising the risk of thromboembolism. The other meals are relatively low in vitamin K and are less likely to significantly interfere with therapy when eaten in typical portions.
Category reason: This question tests patient teaching and safety related to a high-risk medication (warfarin) and food–drug interactions, which is a nursing medication-management judgment area under Pharmacological and Parenteral Therapies.

Question 15

A nurse reviews the medication list of a patient with gout. Which medication would raise concern?

Accepted Answer

Answer reason: Loop diuretics decrease renal urate excretion and can precipitate or worsen hyperuricemia, increasing the risk of gout flares. This makes it a medication that warrants follow-up (e.g., indication, dose, alternatives, and monitoring uric acid/flares) in a patient with gout. In contrast, xanthine oxidase inhibitors and anti-inflammatory prophylaxis are commonly used in gout management.
Category reason: This asks the nurse to identify a medication on a patient’s list that is problematic in gout based on drug adverse effects and contraindications, which fits Pharmacological and Parenteral Therapies (Adverse Effects–Contraindications).

Question 16

A nurse is caring for a client who has been taking amphetamine/dextroamphetamine sulfate for the treatment of adhd for 2 weeks. The nurse should report which of the following findings to the provider?

Accepted Answer

Answer reason: A. Weight loss of 2.3 kg (5lb) Stimulant medications commonly suppress appetite and can cause clinically significant weight loss, especially early in therapy, which may require dose adjustment, nutrition interventions, or medication change. A 2.3 kg (5 lb) loss over 2 weeks suggests an adverse effect that could impact growth/health and should be communicated to the provider. The listed vital signs (BP 110/70, apical pulse 80/min, RR 16) are within expected adult ranges and do not indicate stimulant toxicity in isolation. Reporting the weight loss supports safe monitoring for complications of stimulant therapy.

Question 17

A nurse is caring for a client who has schizoaffective disorder and who has been prescribed chlorpromazine. Which of the following client findings should the nurse monitor after administering the medication?

Accepted Answer

Answer reason: Chlorpromazine is a first-generation antipsychotic with significant alpha-1 adrenergic blocking effects, which can cause orthostatic hypotension. After administration, monitoring for hypotension helps detect an important, common adverse effect that can lead to dizziness, syncope, and falls. This is especially relevant early in therapy or after dose increases when blood pressure drops are more likely. Renal-focused measures like BUN or urine specific gravity are not primary monitoring parameters for this medication’s expected adverse-effect profile. Pedal pulse strength is not a typical targeted assessment for this drug unless there is another vascular concern.

Question 18

A HCP is caring for a pt who is about to receive gentamicin to treat a systemic infection. The healthcare professional should question the use of the drug for a pt who is also taking which of the following drugs?

Accepted Answer

Answer reason: A key safety principle is to avoid combining medications with overlapping organ toxicities. Gentamicin is associated with ototoxicity and nephrotoxicity, and loop diuretics can also increase the risk of ototoxicity, especially when given concurrently or at high doses. This combination raises concern for additive hearing/vestibular damage and warrants questioning, closer monitoring, or alternative therapy. The other listed medications do not have a clinically significant additive ototoxic interaction with gentamicin in typical use.

Question 19

The nurse cares for a client receiving glipizide (Glucotrol) and prednisone (Deltasone). What is the priority nursing assessment?

Accepted Answer

Answer reason: Glipizide increases insulin release and can cause hypoglycemia, while prednisone raises blood glucose through increased gluconeogenesis and insulin resistance. Using these together creates an unstable glycemic picture, so frequent assessment of blood glucose is the most immediate safety priority to detect hypo- or hyperglycemia early. Hemoglobin and platelets are not typical primary monitoring parameters for either medication in routine care. Photosensitivity is not a key expected adverse effect with this drug combination compared with glucose disturbances.

Question 20

A nurse is caring for a patient receiving furosemide (Lasix). Which lab result requires immediate action?

Accepted Answer

Answer reason: Loop diuretics increase urinary potassium losses, so hypokalemia is a predictable and potentially dangerous adverse effect. A potassium of 3.2 mEq/L is low and raises concern for dysrhythmias (especially in patients with cardiac disease or those taking digoxin) and for worsening weakness/cramps. This finding warrants prompt assessment, notification of the provider, and likely potassium replacement and/or adjustment of diuretic therapy. The other values listed (sodium 136, creatinine 1.0, glucose 110) are within or near expected ranges and do not pose the same immediate risk.

Question 21

The LPN/LVN administers filgrastim (Neupogen) 100 mcg IV. It is MOST important for the LPN/LVN to assess for which of the following?

Accepted Answer

Answer reason: Filgrastim is a granulocyte colony-stimulating factor that stimulates neutrophil production, and its most common expected adverse effect is bone pain from increased marrow activity. Gastrointestinal upset (including nausea/vomiting) can also occur and is a realistic monitoring priority after administration. Bruising/bleeding manifestations point more toward thrombocytopenia, which is not the typical effect of filgrastim. Frequent URIs reflect neutropenia/immunosuppression and would be more consistent with the condition being treated rather than a medication adverse effect to newly assess for.

Question 22

An older client recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication?

Accepted Answer

Answer reason: The most commonly reported CNS effect in this population is acute confusion/delirium, which can present as disorientation and altered mental status. Hallucinations can occur but are less frequent and typically reflect more pronounced CNS toxicity. Tremors and dizziness are not the characteristic, most frequent CNS adverse effect emphasized for cimetidine in the elderly, so monitoring should focus on mental status changes.

Question 23

A patient prescribed to citalopram should be instructed to avoid which of the following?

Accepted Answer

Answer reason: Patient teaching commonly includes avoiding alcohol because it can counter therapeutic goals and amplify adverse effects. The other choices are not standard universal avoidances for SSRIs: dark leafy greens relate to warfarin/vitamin K interactions, and insulin has no direct contraindication with citalopram. While some OTC products can interact (e.g., NSAIDs increasing bleeding risk, dextromethorphan/5-HT agents raising serotonin syndrome risk), the blanket instruction to avoid all OTC medications is overly broad; instead patients should consult before using them.

Question 24

A client on warfarin (Coumadin) therapy has an INR of 5.2. What is the nurse’s priority action?

Accepted Answer

Answer reason: 2 indicates supratherapeutic anticoagulation and a significantly increased bleeding risk, so immediate action focuses on reversal and prevention of hemorrhage. Vitamin K is the antidote that restores synthesis of vitamin K–dependent clotting factors and is appropriate when ordered for an elevated INR. Continuing or increasing the anticoagulant would further raise bleeding risk and is unsafe. Dietary counseling about vitamin K intake is not a priority intervention for acute, markedly elevated INR requiring prompt correction.

Question 25

A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?

Accepted Answer

Answer reason: This finding reflects a medication intolerance/side effect that can occur with furosemide and warrants assessment of severity, hydration status, and whether the drug is being taken with food as prescribed. In contrast, weight gain and ankle edema suggest inadequate diuretic effect or worsening fluid retention rather than an adverse effect. Decreased appetite is nonspecific and less directly tied to furosemide than GI irritation.

Question 26

A nursing officer monitors a client receiving digoxin for which early manifestation of digoxin toxicity?

Accepted Answer

Answer reason: Early warning signs include anorexia, nausea, vomiting, and abdominal discomfort before more dramatic cardiac dysrhythmias occur. Visual disturbances such as diplopia can occur but are classically later or with more established toxicity rather than the earliest cue to monitor for. Recognizing anorexia early prompts checking digoxin level and electrolytes (especially potassium) and reassessing dosing to prevent progression.

Question 27

A client with heart failure is prescribed an angiotensin-converting enzyme (ACE) inhibitor. What should the nurse monitor closely during therapy with an ACE inhibitor?

Accepted Answer

Answer reason: Clients with heart failure often have comorbid CKD and may be taking other potassium-raising therapies (e.g., potassium-sparing diuretics), further increasing risk. Monitoring potassium helps prevent dangerous dysrhythmias and neuromuscular symptoms related to elevated potassium. Blood pressure and renal perfusion/urine output are also important, but potassium is the classic and high-yield lab abnormality to monitor closely for this drug class.

Question 28

A physician has ordered aspirin therapy for a client with server rheumatoid arthritis. A sign of acute aspirin toxicity is ?

Accepted Answer

Answer reason: This finding is especially important when high-dose aspirin is used for anti-inflammatory effect in conditions like rheumatoid arthritis. GI upset can occur with aspirin, but it is nonspecific and does not reliably indicate toxicity the way auditory changes do. Prompt recognition is critical because worsening toxicity can progress to acid–base disturbances, hyperventilation, and neurologic deterioration.

Question 29

A patient is on digoxin therapy, what kind of food items a nurse will suggest to him?

Accepted Answer

Answer reason: Encouraging dietary potassium helps maintain normal serum potassium and reduces this toxicity risk, especially in patients also taking potassium-wasting diuretics. A low-potassium diet would worsen hypokalemia and make adverse effects more likely. Salt-free or high-calorie diets are not the key dietary safety teaching specific to digoxin.

Question 30

A nurse is teaching about self administering methotrexate to a client who has rheumatoid arthritis. Which of the following statements should the nurse make?

Accepted Answer

Answer reason: Adequate hydration supports renal perfusion and urinary clearance, helping reduce the risk of accumulation and related toxicity. Doubling a missed dose is unsafe teaching for many high-risk medications, including immunosuppressive agents, because it can increase toxicity risk. NSAIDs can increase methotrexate levels by reducing renal clearance, so advising their use to “reduce toxicity” is inaccurate and potentially harmful.

Question 31

When a 12-year-old child is prescribed methylphenidate, which is most important for the nurse to monitor?

Accepted Answer

Answer reason: Monitoring growth parameters allows early identification of clinically significant weight loss or deviation from expected height progression and supports timely dose adjustment or drug-holiday discussions if needed. This is a high-yield safety monitoring priority compared with routine vital signs when no acute toxicity is suspected. Intake and output is not the primary ongoing concern unless there are specific comorbidities or complications requiring fluid balance monitoring.

Question 32

A nurse is teaching a client about the adverse effects of digoxin. Which of the following statements should the nurse include in the teaching?

Accepted Answer

Answer reason: Digoxin has a narrow therapeutic index, so new symptoms (e.g., nausea, visual changes, bradycardia) warrant evaluation rather than self-management. Instructing a client to change their own dose is unsafe because it can worsen arrhythmia risk or lead to loss of therapeutic effect. Adverse effects are unintended and can occur without an allergy, so the safest teaching is to notify the provider for guidance.

Question 33

A nurse is planning care for a client who has a prescription for methotrexate. The nurse should plan to monitor the client for which of the following adverse effects?

Accepted Answer

Answer reason: Methotrexate is an antimetabolite that inhibits folate-dependent DNA synthesis, so rapidly dividing cells in the bone marrow are particularly vulnerable. This can lead to clinically significant myelosuppression, increasing the risk of infection, anemia-related symptoms, and bleeding. Nursing monitoring focuses on CBC trends and early signs of marrow suppression to prevent severe complications. While thrombocytopenia can occur, it is a subset manifestation of broader myelosuppression, making bone marrow depression the most comprehensive adverse effect to monitor. Visual changes and constipation are not characteristic priority toxicities for methotrexate compared with hematologic suppression.

Question 34

A nurse caring for a client who was diagnosed with post menopausal osteoporosis. Which of the following actions should the nurse take prior to administering calcitonin salmon to the client for the first time?

Accepted Answer

Answer reason: A skin test is used to screen for allergy risk prior to the initial dose to reduce the chance of anaphylaxis or severe allergic response. Liver function testing is not a routine prerequisite because this medication is not primarily hepatotoxic nor dosed by hepatic clearance. Urine sediment and breath sounds do not address the key first-dose safety concern for this drug.

Question 35

A patient is getting ready for surgery and will be administered succinylcholine as general anesthesia. Prior to administration what should Nurse Krystal report to the HCP?

Accepted Answer

Answer reason: g., malignant hyperthermia or atypical pseudocholinesterase variants), which can make neuromuscular blockers and anesthetic agents dangerously high risk. This information can change the anesthesia plan, trigger avoidance of certain agents, and prompt preparedness with appropriate monitoring and rescue measures (such as dantrolene availability for malignant hyperthermia risk). By contrast, being NPO for 10 hours is generally appropriate and not a red-flag contraindication, and having never had surgery is not by itself a contraindication. Reporting the family reaction is a key safety step before administering a paralytic and proceeding with induction.

Question 36

A client with hypertension and asthma takes multiple oral medications. Which medication does the nurse recognize as placing the client at risk for bronchospasm?

Accepted Answer

Answer reason: This medication is nonselective, so it can precipitate bronchospasm and blunt the effect of rescue beta-agonist inhalers. By contrast, ACE inhibitors like lisinopril are more associated with cough/angioedema rather than direct bronchospasm from beta-2 blockade. Calcium channel blockers (amlodipine) and aldosterone antagonists (spironolactone) do not typically cause bronchospasm as a primary adverse effect.

Question 37

The nurse is caring for a client with a diagnosis of glaucoma who is reporting severe nausea. Which of the following medication orders should the nurse question?

Accepted Answer

Answer reason: This drug has prominent anticholinergic effects, so it is a higher-risk antiemetic choice for a client with glaucoma and should prompt the nurse to question the order and clarify the type of glaucoma and safer alternatives. In contrast, a 5-HT3 antagonist is not associated with clinically meaningful increases in intraocular pressure. A dopamine antagonist/prokinetic agent is generally not contraindicated by glaucoma, though it carries other risks (e.g., extrapyramidal effects).

Question 38

A nurse is caring for a patient who has been prescribed warfarin for atrial fibrillation. Which patient statement indicates a need for further teaching?

Accepted Answer

Answer reason: Warfarin increases bleeding risk, and adding NSAIDs further raises the risk by inhibiting platelet function and irritating the gastric mucosa. This combination significantly increases the chance of GI bleeding and other hemorrhagic complications, so the patient should be taught to avoid ibuprofen unless specifically directed. A safer over-the-counter analgesic option is typically acetaminophen in limited doses with provider guidance. Using an electric razor and monitoring INR are appropriate safety behaviors, and dietary counseling should focus on consistent vitamin K intake rather than complete avoidance.

Question 39

A patient is prescribed lithium carbonate for bipolar disorder. Which statement by the patient indicates a need for further teaching?

Accepted Answer

Answer reason: " Lithium is handled by the kidneys similarly to sodium, so low sodium intake or sodium loss increases renal reabsorption of lithium and raises toxicity risk. Teaching should emphasize maintaining consistent, normal dietary sodium rather than restricting it. Adequate fluid intake and reporting vomiting/diarrhea are important because dehydration also elevates lithium levels. Regular blood level monitoring is required due to lithium’s narrow therapeutic index and potential for serious adverse effects.

Question 40

A nurse need to check the most important parameter if patience is on magnesium sulphate therapy.?

Accepted Answer

Answer reason: Monitoring the respiratory rate directly assesses ventilation and identifies impending apnea, which requires immediate action (stop infusion and give calcium gluconate per protocol). Deep tendon reflexes and urine output are also important because loss of reflexes and oliguria indicate rising magnesium levels, but they are less immediately critical than breathing. Blood pressure control is not the primary safety parameter for magnesium toxicity monitoring.

Question 41

The nurse is teaching a client who is receiving newly prescribed clopidogrel. Which of the following information should the nurse include?

Accepted Answer

Answer reason: ” Clopidogrel inhibits platelet aggregation, so the key safety teaching is early recognition and reporting of bleeding manifestations. Unusual bruising can indicate excessive antiplatelet effect or occult bleeding and warrants prompt evaluation to prevent progression to serious hemorrhage. Routine avoidance of acetaminophen is not a standard precaution with clopidogrel; bleeding risk is more clinically relevant with NSAIDs/aspirin rather than acetaminophen. Driving restrictions and serum albumin monitoring are not expected teaching points for this medication.

Question 42

During gentamicin therapy, the nurse should monitor a patient's?

Accepted Answer

Answer reason: Rising serum creatinine indicates reduced glomerular filtration and early kidney injury, which may require dose adjustment or discontinuation. Glucose is not a typical toxicity marker for gentamicin. PTT monitoring is relevant for anticoagulants (e.g., heparin), and potassium abnormalities are not the primary expected adverse effect being screened for with this medication.

Question 43

A nurse is assessing a client who is on digoxin therapy. Which laboratory tests should the nurse review before administration?

Accepted Answer

Answer reason: Hypokalemia increases digoxin binding to the Na+/K+-ATPase and markedly raises the risk of dysrhythmias and toxicity, so potassium should be checked before giving the dose. This is especially important in clients taking loop/thiazide diuretics or with GI losses, where potassium can drop quickly. While calcium and sodium can influence cardiac excitability, potassium is the key lab value most directly linked to digoxin toxicity risk and dosing safety.

Question 44

Before administering ephedrine, Nurse Tony assesses the patient’s history. Because of ephedrine’s central nervous system (CNS) effects, it is not recommended for?

Accepted Answer

Answer reason: Ephedrine can cause nervousness, tremor, insomnia, and agitation, and it can also precipitate cardiovascular complications (e.g., tachycardia, hypertension) that are more dangerous in this population. Because age-related pharmacodynamic changes and comorbidities amplify these risks, ephedrine is generally avoided or used with extra caution in the elderly. By contrast, the other options are not primarily contraindications due to CNS effects and include conditions where stimulatory effects may be therapeutically relevant.

Question 45

Mr. F has been prescribed isocarboxazid, a monoamine oxidase inhibitor, as part of treatment for depression. Which of the following foods should the nurse instruct the client to avoid while taking this drug?

Accepted Answer

Answer reason: This can precipitate a hypertensive crisis (severe headache, markedly elevated BP, palpitations, diaphoresis) that is a classic, high-risk contraindication teaching point. Wine—especially certain aged or fermented types—can be high in tyramine and is commonly included on the avoid list for MAOI therapy. The other listed foods are not typical high-tyramine triggers emphasized in standard MAOI dietary counseling.

Question 46

A female client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs?

Accepted Answer

Answer reason: Streptomycin is an aminoglycoside, and a key serious toxicity is ototoxicity from cochlear/vestibular injury. New tinnitus, diminished hearing, or balance changes can signal potentially irreversible damage and require prompt provider notification and reassessment of therapy. This teaching focuses on early recognition of a high-risk adverse effect to prevent permanent harm. Visual changes like impaired color discrimination are classically associated with ethambutol rather than streptomycin.

Question 47

In teaching a client who has been prescribed a benzodiazepine for panic disorder, the nurse must be certain to do what?

Accepted Answer

Answer reason: Benzodiazepines can cause physiologic dependence, and abrupt cessation can trigger rebound anxiety, tremors, insomnia, and potentially seizures, so tapering under medical supervision is a key safety teaching point. Client education should emphasize using the lowest effective dose for the shortest duration and avoiding sudden discontinuation. Routine biweekly blood draws for pancytopenia monitoring are not standard for benzodiazepines and reflect teaching associated with other medication classes. While sedation and respiratory depression risks are important, the most essential unique safety issue tested here is withdrawal risk with unsupervised stopping.

Question 48

After undergoing a thoracotomy, a male client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia?

Accepted Answer

Answer reason: A thoracotomy patient already has increased risk for hypoventilation due to pain, splinting, and reduced lung expansion, so any opioid-related decrease in respiratory rate or depth can rapidly lead to hypoxemia and hypercapnia. Tachycardia is nonspecific and may reflect pain or anxiety rather than a direct epidural complication. Paresthesias can occur with sensory blockade or transient nerve irritation but are typically less urgent than impaired breathing requiring prompt intervention and possible naloxone/supportive ventilation.

Question 49

Dani was given Dilaudid for pain. She’s sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?

Accepted Answer

Answer reason: A respiratory rate of 4/min indicates severe hypoventilation and imminent failure of ventilation if not rapidly reversed and supported. The most immediate life-threatening progression is apnea leading to arrest, which requires urgent stimulation, airway support, and consideration of naloxone. Constipation is a common opioid effect but is not an acute threat compared with profound bradypnea, and an asthma attack is not the typical direct opioid toxicity pattern.

Question 50

A nurse is speaking on the phone to a client at home who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is most appropriate?

Accepted Answer

Answer reason: " Oral iron commonly causes dark green to black stools due to unabsorbed iron and its oxidation in the gastrointestinal tract, which is a benign, expected effect. The absence of abdominal pain, cramping, or other signs of acute GI bleeding makes reassurance and education the safest and most appropriate nursing response. Advising an office visit or emergency evaluation would be indicated if there were red-flag symptoms such as severe abdominal pain, dizziness/syncope, hematemesis, or tarry stools with other bleeding indicators. Asking about diet may be appropriate if the finding were atypical, but black stools are a well-known, medication-related effect in this context.

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