Question 1

A patient was started on Digoxin for Heart Failure because his partner broke up with him. He was Green and his heart was already three sizes too small, so his heart was just waiting to fail.. Which comment is most concerning by this patient?

Accepted Answer

Answer reason: Digoxin has a narrow therapeutic index, so new GI symptoms after initiation can indicate supratherapeutic levels or heightened sensitivity (e.g., older age, renal impairment, electrolyte abnormalities). While tinnitus can occur with some medications, it is not a classic hallmark finding for digoxin toxicity compared with GI upset and visual disturbances (yellow/green halos). Gingival swelling is more consistent with phenytoin effects rather than digoxin, and the holiday statement reflects mood rather than a medication adverse effect requiring immediate digoxin-focused intervention.

Question 2

Peaked T waves are present on a client's electrocardiogram (ECG). What medication does the nurse withhold from the client until this finding is investigated?

Accepted Answer

Answer reason: A key nursing safety principle is to hold medications that can worsen a dangerous electrolyte abnormality until serum levels and the cause are clarified. Spironolactone is a potassium-sparing diuretic (aldosterone antagonist) that increases potassium retention and can aggravate or precipitate hyperkalemia. In contrast, loop and thiazide diuretics more commonly lower potassium and are not the primary concern for worsening peaked T waves. Withholding the potassium-sparing agent while investigating potassium level and renal function is the safest action.

Question 3

A patient is admitted to the hospital with an acute heart attack. The physician orders the patient Enoxaparin (Lovenox) 1 mg/kg subcutaneous every 12 hours. Before administering the medication, the nurse verifies that the patient understands the side effects of this medication. Which of the following statements from the patient demonstrates that he understands the medication's side effects?

Accepted Answer

Answer reason: " Enoxaparin is a low-molecular-weight heparin anticoagulant, so the key expected adverse effect teaching is bleeding. Patients should report easy bruising, gum/nose bleeding, blood in urine or stool, or prolonged bleeding because these reflect excessive anticoagulation. Although dysrhythmias are not the hallmark side effect to teach for enoxaparin, the option is the only one that correctly includes clinically important bleeding/bruising awareness. The other options describe adverse effects more consistent with other drug classes (e.g., beta-blockers/antihypertensives or respiratory reactions) rather than an anticoagulant.

Question 4

A client admitted to the medical ward for convulsions is receiving intravenous magnesium sulfate. Which of the following signs indicate an expected side effect of the drug?

Accepted Answer

Answer reason: Magnesium sulfate is a CNS depressant and commonly causes mild sedation, lethargy, and a feeling of drowsiness at therapeutic levels. This finding can be expected while the medication is infusing, as long as vital signs and reflexes remain within safe limits. In contrast, loss of deep tendon reflexes and respiratory depression are classic signs of magnesium toxicity and require immediate intervention (e.g., stopping the infusion and preparing calcium gluconate). Decreased urine output is concerning because magnesium is renally excreted and oliguria increases the risk of toxicity rather than representing a routine expected effect.

Question 5

The nurse provides care for a client with a theophylline level of 32 mcg/mL. Which assessment finding indicates a need for priority action by the nurse based on the current data?

Accepted Answer

Answer reason: A markedly elevated theophylline level indicates toxicity with a narrow therapeutic index, and severe toxicity can rapidly progress to life-threatening CNS effects. Seizure activity is an emergency because it threatens airway, breathing, and circulation and requires immediate intervention (stop drug, support ABCs, obtain emergency treatment/antidotes per protocol). Other findings such as GI discomfort can occur with toxicity but are not as immediately life-threatening as a generalized seizure. Gingival changes are not characteristic of theophylline toxicity and would not match the urgency implied by the lab value.

Question 6

The nurse is caring for a client in labor who has butorphanol tartrate (Stadol) prescribed for the relief of labor pain. During the administration of the medication, the nurse should ensure that which priority item is readily available?

Accepted Answer

Answer reason: The priority is to have an opioid antagonist available to rapidly reverse opioid-induced respiratory depression and restore adequate ventilation if it occurs. Naloxone is the specific reversal agent for opioid effects and is therefore the essential safety medication to keep at the bedside. Alternatives like another opioid or antiemetic do not address airway/ventilation compromise and are not the immediate priority in an overdose or excessive sensitivity scenario.

Question 7

The clinic nurse is preparing to administer atropine eye drops to a client undergoing an eye exam. Which of the following actions should the nurse take before administration?

Accepted Answer

Answer reason: Atropine is an anticholinergic that causes mydriasis and cycloplegia, which can obstruct aqueous outflow and precipitate acute angle-closure glaucoma in susceptible patients. Screening for a glaucoma history (and related risk) is a key safety step before giving a mydriatic agent. Mild burning can occur and is generally expected/brief rather than an urgent reportable adverse effect. Sunglasses are appropriate teaching after dilation, and checking vital signs is not the primary pre-administration safety concern for routine ophthalmic use.

Question 8

The nurse is assessing a client who recently started taking tamsulosin. Which of the following client statements would require follow-up?

Accepted Answer

Answer reason: " Tamsulosin is an alpha-1 blocker that can cause orthostatic hypotension, and combining it with phosphodiesterase-5 inhibitors can significantly increase the risk of dangerous symptomatic hypotension and syncope. This statement shows the client is planning an unsafe self-management step and needs counseling to avoid taking erectile dysfunction drugs without prescriber guidance. Nasal congestion is a known alpha-1 blocker side effect that is usually nonurgent. Dizziness when standing and compensating by standing slowly reflects appropriate orthostatic precautions, while altered ejaculation with cloudy urine can occur from retrograde ejaculation and should be discussed but is not as immediately safety-threatening as the drug interaction risk.

Question 9

The nurse is aware that the supplemental medication most frequently ordered in conjunction with furosemide (Lasix) is?

Accepted Answer

Answer reason: Loop diuretics increase urinary excretion of electrolytes, with potassium loss being a common and clinically important adverse effect. This creates risk for hypokalemia, which can cause muscle weakness, dysrhythmias, and potentiation of cardiac glycoside toxicity. Therefore potassium is frequently supplemented or potassium levels are closely monitored and replaced as needed when a patient is receiving furosemide. Sodium supplementation is generally not routine because furosemide is used to reduce sodium and water excess, and adding sodium would counter therapeutic goals.

Question 10

Which drug should a nurse choose to use as an antagonist for magnesium sulfate?

Accepted Answer

Answer reason: g., loss of deep tendon reflexes, respiratory depression, hypotension) by antagonizing calcium-mediated excitation. The specific antidote is IV calcium, which rapidly reverses these life-threatening effects by restoring calcium-dependent neuromuscular transmission and myocardial contractility. This is why calcium gluconate is kept readily available when a client is receiving magnesium sulfate for preeclampsia or tocolysis. Oxytocin and terbutaline affect uterine activity, and naloxone reverses opioid effects, so none of those address magnesium toxicity.

Question 11

A client is receiving pentamidine isethionate (Pentam). What is the most important assessment by the nurse?

Accepted Answer

Answer reason: This adverse effect can be abrupt and life-threatening, so bedside monitoring and prompt intervention are priority nursing assessments. Compared with routine CBC or electrolytes, abnormal glucose is both more characteristic of this drug and more likely to produce immediate neurologic compromise. Therefore, frequent blood glucose checks are the most important assessment focus while the client is receiving therapy.

Question 12

The nurse is aware that antihypertensives should be used cautiously in clients already taking which other drug?

Accepted Answer

Answer reason: This interaction can make hypertension harder to control and can worsen renal perfusion, especially in older adults or those with CKD. NSAIDs also increase the risk of kidney injury when combined with ACE inhibitors/ARBs and diuretics (“triple whammy”). In contrast, routine vitamins generally do not counteract antihypertensive efficacy in a predictable, clinically significant way.

Question 13

A client has just started taking phenytoin (Dilantin) and asks the nurse if there are any adverse effects to be aware of. The best response by the nurse is?

Accepted Answer

Answer reason: Phenytoin is a CNS-active antiepileptic, so dose-related central nervous system depression (drowsiness, dizziness, ataxia, nystagmus) is a common early adverse effect clients should anticipate and report if severe. This option directly reflects a typical and expected medication effect that impacts safety (e.g., driving/fall risk), making it the best nursing teaching point. Dry mouth is more characteristic of anticholinergic medications rather than phenytoin. Tachycardia is not a typical adverse effect with oral maintenance dosing and is more associated with rapid IV administration causing dysrhythmias/hypotension.

Question 14

Which assessment finding would lead the nurse to suspect a child has a level greater than 2 mcg/ml?

Accepted Answer

Answer reason: GI symptoms such as anorexia, nausea, and vomiting often appear before more dangerous cardiac dysrhythmias and therefore are key assessment cues for elevated levels in children. Tachycardia is less typical as an initial toxicity sign; bradycardia and conduction blocks are more characteristic. Seizures can occur with severe toxicity but are not the most likely early finding compared with GI upset.

Question 15

A client is prescribed isotretinoin (Accutane). Which adverse effect should the nurse include in her teaching?

Accepted Answer

Answer reason: Exposure during pregnancy can cause severe congenital malformations, which is why strict contraception requirements and pregnancy testing programs are mandated. The other choices are more typical of antibiotic therapy (e.g., yeast infections) or are not the hallmark safety concern emphasized with this medication. The priority adverse effect to teach is therefore the risk of serious birth defects and the need to avoid pregnancy.

Question 16

A client has received dinoprostone (Prostin E2) for cervical ripening. It is most important for the nurse to assess the client for which of the following?

Accepted Answer

Answer reason: Assessing for nausea/vomiting is therefore a high-yield, expected effect that can impact hydration status and tolerance of therapy. In contrast, uterine inversion is a rare obstetric emergency typically associated with the third stage of labor/placental traction, not a direct expected adverse effect of cervical ripening agents. Constipation and euphoria are not characteristic or priority assessments for prostaglandin E2 administration.

Question 17

Which adverse reaction can be attributed to a medication in the classification of tricyclic antidepressants?

Accepted Answer

Answer reason: Tricyclic antidepressants (TCAs) have prominent anticholinergic effects, which reduce sweating and impair heat dissipation, predisposing the patient to hyperthermia, especially in warm environments or with overdose. This aligns with an elevated body temperature as an adverse effect to monitor alongside dry mouth, urinary retention, constipation, and tachycardia. Miosis and hypersecretions are more consistent with cholinergic excess (e.g., organophosphate toxicity) rather than the anticholinergic profile of TCAs. Pallor is not a characteristic or high-yield adverse reaction specific to TCAs compared with their anticholinergic and cardiotoxic effects.

Question 18

Sublingual nitroglycerin is given to a client who experiences chest pain. Which symptom can occur with this medication?

Accepted Answer

Answer reason: Nitrates cause systemic vasodilation, which can lead to a drop in blood pressure. The body may compensate through baroreceptor-mediated sympathetic activation, producing reflex tachycardia. This effect can accompany other common nitrate effects such as headache, flushing, and dizziness from hypotension. The other options are not typical adverse effects associated with sublingual nitroglycerin in routine use.

Question 19

Which electrolyte imbalances should be of concern for the client taking digoxin (Lanoxin)?

Accepted Answer

Answer reason: Digoxin toxicity risk increases when serum potassium is low because potassium competes with digoxin at the Na+/K+ ATPase pump; reduced potassium allows greater digoxin binding and effect. This potentiation predisposes the client to dysrhythmias and other toxicity manifestations even at therapeutic digoxin levels. Electrolyte depletion can occur with concurrent diuretic therapy, making monitoring especially important in heart failure patients. While low magnesium can also increase dysrhythmia risk, the classic highest-yield electrolyte imbalance that raises digoxin sensitivity is low potassium.

Question 20

Which nursing diagnosis is the highest priority for the client taking analgesic agents?

Accepted Answer

Answer reason: Analgesic agents—especially opioid analgesics—can depress the respiratory drive and reduce respiratory rate and depth, creating an immediate threat to oxygenation and ventilation. Using ABC priorities, breathing problems outrank other potential complications because hypoventilation can rapidly lead to hypoxemia, hypercapnia, and respiratory arrest. This diagnosis directly targets the most life-threatening adverse effect requiring close monitoring (sedation level, RR, pulse oximetry) and rapid intervention if deterioration occurs. While constipation and injury risk are common with analgesics, they are typically less acute and are managed after ensuring adequate airway and breathing.

Question 21

To which groups of clients should the live intranasal vaccine be administered?

Accepted Answer

Answer reason: Live attenuated intranasal influenza vaccine is indicated only for nonpregnant, immunocompetent people within the approved age range because live vaccines can cause disease in those with impaired immune defenses. Chemotherapy and HIV are associated with immunosuppression, which increases risk from live attenuated vaccines and makes them contraindicated. Pregnancy is also a contraindication to live attenuated influenza vaccine due to theoretical fetal risk, and inactivated influenza vaccine is preferred instead. The 5–49 age group is the standard eligibility window in which benefits outweigh risks when no contraindications are present.

Question 22

Which sign alerts a nurse to a possible mild toxic reaction in a client receiving lithium for manic episodes of manic-depressive illness?

Accepted Answer

Answer reason: Nausea, vomiting, and diarrhea can indicate rising lithium levels and risk of progression, especially if dehydration or sodium loss is present. This finding should prompt holding the dose per protocol and obtaining a lithium level and hydration assessment. Seizures are more consistent with severe toxicity rather than mild toxicity, while hypertension and increased appetite are not typical early toxicity markers.

Question 23

The nurse is administering corticosteroid therapy to a client. The nurse should be alert for which of the following adverse effects of this therapy?

Accepted Answer

Answer reason: This fluid retention can precipitate or worsen edema and decompensated heart failure, especially in clients with underlying cardiac disease. In contrast, corticosteroids more commonly cause hyperglycemia (not hypoglycemia) by increasing gluconeogenesis and causing insulin resistance. They are also more associated with hypernatremia rather than hyponatremia because of sodium retention. Therefore, monitoring for signs of volume overload and heart failure is a key safety focus during therapy.

Question 24

Which assessment finding is expected in a client receiving bicalutamide (Casodex) and leuprolide (Lupron) for advanced prostate cancer?

Accepted Answer

Answer reason: A common expected assessment finding is episodic flushing and sweating due to hypothalamic thermoregulatory changes from low androgen levels. Abdominal distention is not a typical expected effect of these agents and would prompt evaluation for other causes (e.g., bowel obstruction, ascites). Colicky pain suggests ureteral/renal colic and is unrelated to these medications’ usual adverse-effect profile, while acromegaly reflects excess growth hormone rather than prostate-cancer hormonal therapy.

Question 25

A nurse is teaching a female client about the use of isotretinoin (Accutane). The nurse determines that teaching was effective when the client states the need to take?

Accepted Answer

Answer reason: Isotretinoin is a highly teratogenic medication, so preventing pregnancy is a critical safety requirement for any client who can become pregnant. Effective teaching is demonstrated when the client recognizes the need for strict contraception to avoid severe fetal malformations. Supportive PRN medications for symptoms like nausea, pain, or diarrhea are not universally required and do not address the major contraindication and risk management priority. The key patient-safety focus with this drug is pregnancy prevention through reliable contraception and adherence to risk-management requirements.

Question 26

The client with GERD is taking Cimetidine. Which serum laboratory finding should the nurse determine is most concerning?

Accepted Answer

Answer reason: This is more concerning than benign or nonspecific lab variation because it indicates potential organ damage and risk of progression if therapy continues. A decreased creatinine is typically not worrisome (renal impairment would more often raise creatinine), and cimetidine’s endocrine effect is classically increased prolactin (gynecomastia/galactorrhea), not decreased. An increased platelet count is not a typical high-risk adverse effect associated with this medication compared with evidence of hepatic injury.

Question 27

The nurse is caring for the client who is 1 hour postpartum. Which vital sign should the nurse check before administering methylergonovine 1M?

Accepted Answer

Answer reason: Because hypertension (including preeclampsia/eclampsia) is a key contraindication, the nurse must assess for elevated pressure immediately prior to dosing to prevent hypertensive crisis or stroke. Postpartum patients can have evolving hemodynamics, so a recent reading is essential for safe administration. Other vital signs may be assessed routinely, but they do not screen for the most serious and medication-specific risk associated with this drug.

Question 28

The postpartum client experiencing uterine atony is to receive carboprost tromethamine. Due to the medication side effects, what should the nurse plan to give to the client?

Accepted Answer

Answer reason: Anticipating and treating these effects supports tolerance of therapy while the medication is used to manage uterine atony and prevent postpartum hemorrhage. Planning to administer an antiemetic directly addresses the most clinically significant and frequent symptom that can compromise comfort and hydration. Options like a sedative or stool softener do not target the expected acute adverse effects, and extra fluids may help dehydration risk but do not treat the primary symptom driver (emesis).

Question 29

The nurse is reviewing client information for adverse effects of trazodone. Which finding should the nurse identify as an adverse effect unique to trazodone?

Accepted Answer

Answer reason: This adverse effect is considered a hallmark “unique” warning for trazodone and requires urgent evaluation to prevent ischemic injury and permanent erectile dysfunction. Other listed effects can occur with various antidepressants or other psychotropics and are not specifically characteristic in the same way. Recognizing this risk is essential for patient teaching and prompt escalation if symptoms occur.

Question 30

A client with a myocardial infarction has received a thrombolytic agent. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Thrombolytic therapy dissolves fibrin clots and markedly increases the risk of serious bleeding. Nursing care therefore prioritizes bleeding precautions by minimizing invasive procedures and preventing tissue trauma that could lead to hemorrhage. Avoiding venipunctures/IM injections and applying prolonged pressure if access is necessary directly reduces the most life-threatening complication. Monitoring potassium or encouraging fluids may be relevant in some MI contexts, but they do not address the highest immediate safety risk created by thrombolytics.

Question 31

A nurse should tell parents to stop the administration of acetylsalicylic acid (aspirin) and notify a physician if their child is exposed to which of the following?

Accepted Answer

Answer reason: Influenza is a classic viral trigger associated with this aspirin-related complication, so exposure or suspected infection warrants stopping the drug and contacting the provider. The key nursing safety action is recognizing this contraindication early to prevent neurologic deterioration and liver injury. The other options do not carry this specific aspirin-related risk in pediatrics.

Question 32

A parent asks the nurse if medications can cause Reye’s syndrome. The most appropriate response by the nurse is that Reye’s syndrome has been connected to?

Accepted Answer

Answer reason: Reye syndrome is a rare but serious acute encephalopathy with hepatic dysfunction that is classically associated with salicylate exposure during or after certain viral illnesses in children (especially influenza and varicella). Therefore the key medication risk to teach parents to avoid in children and adolescents with viral symptoms is salicylates. Acetaminophen and ibuprofen are common antipyretic alternatives without this classic association. This is tested as a medication contraindication/safety teaching point in pediatric care.

Question 33

A client receives an injection of promethazine (Phenergan). Which manifestation can occur if the patient has an adverse reaction to this medication?

Accepted Answer

Answer reason: Promethazine can cause extrapyramidal symptoms due to dopamine antagonism, leading to acute dystonic reactions. An acute dystonia may present with painful muscle spasms of the neck and abnormal head positioning, classically torticollis, shortly after administration (especially parenteral). Recognizing this as a medication-induced reaction is important because it requires prompt treatment (e.g., diphenhydramine or benztropine) and monitoring for airway/neck involvement. Nystagmus is not a typical hallmark of promethazine-related EPS, and excessive salivation is more characteristic of cholinergic excess rather than an antihistamine/antiemetic adverse effect. Hyperthermia would raise concern for rare neuroleptic malignant syndrome, but an acute dystonic reaction is the more expected adverse manifestation tested here.

Question 34

When meperidine (Demerol) is used too often for chronic pain, a metabolite known as normeperidine can build up in the body. The nurse knows one of the effects of this metabolite is?

Accepted Answer

Answer reason: Normeperidine is a neurotoxic metabolite of meperidine that can accumulate with repeated dosing, especially in chronic use or renal impairment. Its central nervous system excitatory effects can cause tremors, agitation, and progress to seizures, which is a key safety concern with meperidine. This toxicity is not explained by typical opioid effects (which are more associated with sedation and respiratory depression). Therefore, seizure risk is the hallmark adverse effect linked to normeperidine accumulation.

Question 35

A nurse is assessing a client with manic-depressive disorder. The client tells the nurse his family physician prescribed lithium. Which symptom indicates the client is developing lithium toxicity?

Accepted Answer

Answer reason: New-onset drowsiness, slowed cognition, and decreased responsiveness are warning signs that require prompt evaluation of lithium level and hydration/renal status. Hypertension is not a typical toxicity hallmark, and agitation/hyperexcitability is more consistent with an untreated manic state than lithium excess. Low urine output can contribute to rising lithium levels due to reduced renal clearance, but it is not as characteristic an early clinical manifestation of toxicity as neurologic slowing.

Question 36

A client with diabetes insipidus is receiving desmopressin (DDAVP). Immediate intervention is necessary if the client develops which adverse effect?

Accepted Answer

Answer reason: Desmopressin can cause adverse effects like headache or mild GI symptoms, but these are typically not immediately dangerous and are managed with assessment and supportive care. Injection-site burning is usually localized irritation rather than an emergent systemic reaction. The presence of dyspnea is the key red flag that makes this option the priority for urgent intervention.

Question 37

Hydrocodone with acetaminophen has been prescribed for a client with metastatic prostate cancer. Which of the following is an adverse effect of the medication that the nurse should instruct the client to report?

Accepted Answer

Answer reason: This is a clinically important effect to report because persistent symptoms may require dose adjustment, antiemetic therapy, or evaluation for complications (e.g., dehydration, aspiration risk). Diarrhea is less consistent with opioid therapy, which more typically produces constipation. While mild CNS effects can occur, the most expected reportable adverse effect among these choices is significant nausea/vomiting.

Question 38

The nurse is caring for the client taking atorvastatin. The nurse should assess for which adverse effects?

Accepted Answer

Answer reason: Muscle injury risk increases with higher doses and interacting drugs that raise statin levels, and it may be accompanied by dark urine or markedly elevated CK. This finding is more specific and safety-relevant for atorvastatin than nonspecific fatigue or cardiovascular effects. Flushing with orthostatic symptoms is more characteristic of niacin or vasodilators, not HMG-CoA reductase inhibitors.

Question 39

Oral terbutaline is prescribed for the client with bronchitis. Which comorbidity most warrants the nurse’s close monitoring of the client following administration of terbutaline?

Accepted Answer

Answer reason: A client with pre-existing elevated blood pressure is at higher risk for clinically significant cardiovascular stimulation and related complications, so vital signs and symptoms should be monitored closely after dosing. This also helps detect dysrhythmias early, which can be precipitated by sympathomimetic medications. By contrast, eye alignment disorders and hypothyroidism are not typical conditions that amplify this medication’s most concerning adverse effects in the immediate post-dose period.

Question 40

The nurse is assessing the female client who is taking clomiphene. Which finding should indicate to the nurse that the client is experiencing an adverse effect of the medication?

Accepted Answer

Answer reason: This symptom is clinically important because it can signal significant ovarian cyst formation or evolving hyperstimulation that requires prompt evaluation and possible discontinuation. Nipple discharge is more suggestive of hyperprolactinemia or pituitary pathology rather than a typical clomiphene adverse effect. Watery diarrhea is not a characteristic adverse reaction for this medication in ovulation induction and is less specific and less safety-relevant than pelvic pain.

Question 41

The breastfeeding postpartum client is reporting afterpains and requests pain medication. Which medication is best for the nurse to select to prevent adverse effects on her breastfeeding infant?

Accepted Answer

Answer reason: This option is commonly recommended postpartum because breast milk levels are low, it has a short half-life, and it effectively treats uterine cramping/inflammatory pain. An opioid like meperidine is avoided due to metabolite accumulation and risk of infant sedation/respiratory depression. Naproxen is less preferred because of its longer half-life and greater potential for infant exposure with repeated dosing.

Question 42

The client admitted to the ED has drowsiness, clammy skin, and slow, shallow breathing. A friend states that the client took multiple oxycodone tablets. Which medication should the nurse plan to administer to this client?

Accepted Answer

Answer reason: The appropriate immediate antidote is an opioid receptor antagonist that rapidly reverses opioid effects and improves ventilation. The other options target different toxicities (benzodiazepines, acetaminophen, alcohol use disorder) and would not correct opioid-induced hypoventilation. After administration, the nurse must anticipate re-sedation due to shorter antagonist duration compared with many opioids and monitor airway/respiratory status closely.

Question 43

A client is receiving spironolactone to treat hypertension. Which instruction should the nurse provide?

Accepted Answer

Answer reason: Spironolactone is a potassium-sparing diuretic that reduces potassium excretion, creating a clinically significant risk for hyperkalemia. Many salt substitutes use potassium chloride, so using them can further raise serum potassium and precipitate dysrhythmias or muscle weakness. Teaching should therefore focus on avoiding added potassium sources and monitoring for signs of elevated potassium. Options encouraging high-potassium foods or supplements are unsafe with this medication, and stopping sodium restriction undermines hypertension management.

Question 44

The laboratory has just notified the nurse that a client on the unit has a phenytoin level of 32 mg/dl. The nurse would expect the client to display which symptom(s)?

Accepted Answer

Answer reason: At levels above the therapeutic range (about 10–20 mcg/mL), patients commonly develop nystagmus, ataxia, slurred speech, dizziness, and altered mental status such as confusion. A reported level of 32 indicates toxicity, making cerebellar/neurologic findings the expected presentation. Sodium depletion is more characteristic of carbamazepine/oxcarbazepine-related SIADH, and seizures would be more consistent with subtherapeutic levels or withdrawal rather than overdose.

Question 45

A nurse has administered atropine to an 11-month-old infant for the treatment of sinus bradycardia. The nurse would be most concerned if the infant displayed which adverse reaction?

Accepted Answer

Answer reason: New-onset lethargy in an infant can signal significant adverse CNS effects or worsening hemodynamic status despite treatment, making it the most concerning finding requiring immediate reassessment of airway, breathing, circulation, and rhythm. The other options reflect expected anticholinergic drying and urinary retention patterns (not increased urine output), and diarrhea is opposite of the typical atropine effect (it more often decreases GI motility). In infants, reduced responsiveness is a high-risk sign and is prioritized over non–life-threatening anticholinergic side effects such as decreased secretions.

Question 46

The nurse is preparing to administer the postoperative client’s first dose of morphine sulfate through PCA. The nurse should also ensure that which antagonist medication is readily available?

Accepted Answer

Answer reason: Naloxone is a competitive opioid receptor antagonist that rapidly reverses opioid-induced respiratory depression. Flurmazinel is used to reverse benzodiazepines, not opioids. Digoxin immune fab and protamine sulfate are antidotes for digoxin and heparin, respectively, and do not address opioid toxicity.

Question 47

A client with gestational hypertension is receiving magnesium sulfate to prevent seizure activity. The nurse reviews the magnesium level and identifies a therapeutic level as?

Accepted Answer

Answer reason: Magnesium sulfate is titrated to a narrow therapeutic range that provides anticonvulsant effect while avoiding toxicity that depresses neuromuscular and respiratory function. A serum level in this range is consistent with effective seizure prophylaxis in gestational hypertension/preeclampsia. Higher levels increase risk of loss of deep tendon reflexes and respiratory depression, progressing to cardiac conduction problems at severe toxicity. Therefore, the option listing the therapeutic target range is the safest and most clinically appropriate choice.

Question 48

A client receives a dose of furosemide (Lasix) 120 mg intravenously for treatment of congestive heart failure. Which symptom indicates that an adverse reaction is most likely occurring?

Accepted Answer

Answer reason: IV furosemide is a potent loop diuretic that can cause rapid intravascular volume depletion and venodilation, leading to decreased preload and a drop in blood pressure. A 120 mg IV dose increases the risk for excessive diuresis, especially in clients with heart failure who may already have tenuous hemodynamics. Bradycardia is not a typical direct adverse effect of furosemide, whereas hypotension is a common and clinically important complication requiring assessment and possible intervention. Weight gain and crackles more strongly suggest persistent fluid overload/ineffective diuresis rather than an adverse reaction to the medication.

Question 49

Which dietary change must a client make when starting treatment with the medication spironolactone (Aldactone)?

Accepted Answer

Answer reason: Spironolactone is a potassium-sparing diuretic (aldosterone antagonist) that reduces potassium excretion, creating a clinically important risk of hyperkalemia. Many salt substitutes replace sodium with potassium chloride, which can significantly increase potassium intake and worsen this adverse effect. Therefore, client teaching should focus on avoiding potassium-containing salt substitutes and monitoring for hyperkalemia, especially in clients with renal impairment or those taking ACE inhibitors/ARBs. Options encouraging potassium-rich foods (e.g., bananas, many leafy greens) increase risk rather than prevent it.

Question 50

A client who takes morphine sulfate (morphine) for pain control may have which potential nursing diagnose as part of the care plan?

Accepted Answer

Answer reason: Opioids can depress the medullary respiratory center, decreasing respiratory rate and tidal volume and leading to hypoventilation. This raises PaCO2 and can lower oxygenation, creating a real risk for ventilation-perfusion mismatch and impaired alveolar gas transfer. A nursing diagnosis focused on respiratory function is therefore the most safety-relevant potential problem when morphine is used, especially in opioid-naïve clients, older adults, or those with underlying lung disease. The other options are not typical primary effects of morphine and are less directly tied to its most serious adverse outcome (respiratory depression).

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