Question 1

A nurse anticipates that a client who has been prescribed corticosteroids would also have an order for?

Accepted Answer

Answer reason: Systemic corticosteroids increase insulin resistance and stimulate gluconeogenesis, so hyperglycemia is a common and clinically important adverse effect even in clients without known diabetes. Scheduled bedside glucose monitoring helps detect steroid-induced hyperglycemia early and guides timely treatment adjustments. Fluid restriction is not a routine accompanying order for corticosteroid therapy and would depend on a separate condition such as severe heart failure or hyponatremia. Lactulose is used for hepatic encephalopathy/constipation and frequent CBC/platelet surveillance is not a standard monitoring requirement solely due to corticosteroid administration.

Question 2

An infant with hypothyroidism is receiving oral thyroid hormone. The nurse is most concerned about which assessment findings?

Accepted Answer

Answer reason: A hypermetabolic/sympathetic picture (fast heart rate, increased sweating, and marked irritability) is a concerning adverse effect pattern that warrants prompt provider notification and likely dose adjustment. In contrast, bradycardia, cool extremities, excessive sleepiness, and dry skin are consistent with undertreated hypothyroidism rather than medication excess. Among the choices, the cluster that best matches thyroid hormone over-replacement is the one with tachycardia and diaphoresis.

Question 3

The nurse is teaching the mother of a child with lice about treatment options. What is the most important information for the nurse to include when discussing lindane (Kwell) shampoo?

Accepted Answer

Answer reason: Lindane is a potentially neurotoxic pediculicide, and systemic absorption can cause serious CNS adverse effects. The key safety teaching is to minimize exposure and recognize that seizures are a major risk, especially in children or with improper use (over-application, prolonged contact time, or use on broken skin). Because of this toxicity profile, it is generally not first-line compared with safer agents and should be used only exactly as directed. Other listed effects like alopecia, hypertension, or routine LFT elevation are not the primary, high-priority safety warning emphasized in patient education.

Question 4

Neonatal chronic lung disease (bronchopulmonary dysplasia) can cause increased fluid in the lungs due to disruption of the alveolar-capillary membrane, and the client may begin receiving furosemide (Lasix). Which adverse effect is possible?

Accepted Answer

Answer reason: In neonates receiving furosemide, hypokalemia can develop and predispose to dysrhythmias, making an irregular rhythm a key adverse effect to monitor. The other electrolyte options do not match typical furosemide effects: it more commonly causes low potassium and can also lower calcium rather than raising it. Clinically, monitoring serum electrolytes and ECG/heart rate trends helps detect this complication early.

Question 5

A client admitted to the unit for treatment of an upper respiratory infection receives erythromycin lactobionate (Erythromycin). The client has a history of renal transplant and is taking cyclosporine (Neoral). These two medications can interact at which pharmacological phase?

Accepted Answer

Answer reason: Many clinically significant drug–drug interactions occur via hepatic CYP450 enzyme inhibition or induction, which alters drug clearance and serum levels. Erythromycin is a known CYP3A4 inhibitor, and cyclosporine is primarily metabolized by CYP3A4, so co-administration can increase cyclosporine concentrations and toxicity risk (notably nephrotoxicity) in a transplant patient. This is a metabolic interaction rather than one primarily affecting GI uptake or tissue binding. Excretion is less central here because the key mechanism is reduced enzymatic breakdown before elimination.

Question 6

A client is unemployed, has no health insurance, hasn’t filled his levothyroxine (Synthroid) prescription for some time, and has been getting “sicker by the day.” Which problem is probably related to him not taking his medication?

Accepted Answer

Answer reason: Rectal temperature of 94° F (34.4° C) Stopping thyroid hormone replacement leads to worsening hypothyroidism with a global slowing of metabolic processes. A key manifestation is hypothermia due to decreased heat production, and severe cases can progress toward myxedema coma. The other options are more consistent with hyperthyroidism/thyroid hormone excess (tachycardia, warm flushed skin, GI hypermotility). Given he has been without levothyroxine and is progressively “sicker,” hypothermia best fits the expected deterioration from untreated hypothyroidism.

Question 7

A nurse is evaluating drug therapy effectiveness in a client undergoing alcohol detoxification. Which finding indicates that drug therapy needs to be adjusted?

Accepted Answer

Answer reason: Medication effectiveness and safety are evaluated by balancing therapeutic benefit against adverse effects. Evidence of toxicity indicates the current regimen is unsafe and requires prompt dose reduction, medication change, or additional monitoring to prevent harm (e.g., oversedation or respiratory depression during detox treatment). By contrast, preventing further problems and improved interactions with staff are desirable therapeutic outcomes rather than reasons to alter therapy. An increased dosage alone does not prove the therapy is inappropriate; it can be part of a planned titration unless adverse effects occur.

Question 8

The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client understands the discharge teaching?

Accepted Answer

Answer reason: " Antibiotics can disrupt normal vaginal flora, allowing Candida overgrowth, so recognizing this common adverse effect shows accurate medication teaching comprehension. Penicillin courses should be taken exactly as prescribed rather than an arbitrary “7 days only,” especially in conditions linked to streptococcal infection and prevention of recurrence. Claiming there will be “no problems” is an unrealistic guarantee and ignores possible side effects or allergic reactions. Rheumatic fever is classically a sequela of group A streptococcal pharyngitis, not staphylococcal infection, making the throat culture statement incorrect.

Question 9

A client has been placed on prednisone therapy. The client asks the nurse if any adverse reactions can occur when taking the medication. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: They also suppress immune and inflammatory responses and impair collagen synthesis, which delays tissue repair and slows wound healing. This combination is clinically important because it increases infection risk and complicates care for clients with diabetes or those recovering from procedures. Other options include effects that are less characteristic or pair a plausible effect with an incorrect one (e.g., constipation is not a typical hallmark adverse effect of prednisone).

Question 10

The nurse is caring for the client receiving combination chemotherapy of oxaliplatin, fluorouracil, and leucovorin. The nurse should assess the client for which common side effects of this chemotherapy regimen?

Accepted Answer

Answer reason: Fluorouracil frequently produces gastrointestinal toxicity, particularly diarrhea, due to injury of rapidly dividing intestinal mucosa. Leucovorin potentiates fluorouracil’s effects, which can increase the likelihood/severity of fluorouracil-related GI toxicity. The other options describe effects that are not typical signature toxicities of this regimen (e.g., prominent cardiomyopathy or photophobia are not expected as common pattern findings).

Question 11

The client with advanced prostate cancer is receiving abarelix- Due to the effects of the medication, what should be the nurse’s priority?

Accepted Answer

Answer reason: Immediate post-dose monitoring is prioritized when a medication carries risk for rapid-onset, potentially life-threatening hypersensitivity reactions. Abarelix (a GnRH antagonist) is associated with acute systemic allergic reactions that can occur shortly after administration, making short-interval observation and readiness to treat airway/breathing/circulation problems the safest nursing priority. This choice reflects the NCLEX priority of addressing the most serious, time-sensitive adverse effect over longer-term or less dangerous effects. Constipation, sleep issues, and breast tenderness may occur but do not typically require immediate post-administration surveillance to prevent sudden deterioration.

Question 12

The client has a new prescription for metoclopramide- The nurse notifies the HCP because the client has a contraindication for metoclopramide use. Which information in the client’s medical record most likely prompted the nurse’s notification of the HCP?

Accepted Answer

Answer reason: Clients with a seizure disorder are at higher risk for seizure exacerbation when exposed to agents that increase dopaminergic blockade–related neurologic adverse effects. Therefore, the nurse should question the order and notify the HCP to consider an alternative antiemetic/prokinetic. In contrast, diabetes and chemotherapy are common contexts where this medication may be used (eg, diabetic gastroparesis and chemotherapy-associated nausea) rather than contraindications.

Question 13

The nurse is teaching the client about metronidazole, which has been prescribed for treating trichomoniasis. Which client comment indicates the need for additional education?

Accepted Answer

Answer reason:  Metronidazole can cause a disulfiram-like reaction when combined with alcohol due to inhibition of aldehyde dehydrogenase, leading to acetaldehyde accumulation. This can produce flushing, severe nausea/vomiting, abdominal cramping, tachycardia, and headache, so clients must avoid alcohol during therapy and for at least 24–48 hours after the last dose. Metallic taste and GI upset are common expected adverse effects that do not indicate misunderstanding. Darkened urine can also occur and is generally benign, so it likewise reflects appropriate education rather than a need for reteaching.

Question 14

The nurse receives medication orders for the client who is 28 weeks pregnant and experiencing CHF. Which medication should be clarified with the HCP before administration?

Accepted Answer

Answer reason: g., fetal renal dysgenesis, oligohydramnios, skull hypoplasia, neonatal renal failure, and death). At 28 weeks gestation, this risk is particularly high, so the nurse should hold the dose and clarify the order before giving it. In contrast, loop diuretics, digoxin, and selected beta-blockers may be used in pregnant patients with heart failure when clinically indicated, with monitoring for maternal hemodynamics and fetal growth. The key nursing safety action is to identify the pregnancy-specific contraindication and seek an alternative therapy.

Question 15

The nurse is educating the adolescent client about simvastatin. Which information should the nurse include when teaching the client?

Accepted Answer

Answer reason: Statins can cause myopathy that may progress to rhabdomyolysis, a rare but serious adverse effect that requires prompt evaluation. New muscle pain/weakness with dark urine suggests muscle breakdown with myoglobinuria and risk for acute kidney injury. Teaching should emphasize reporting these symptoms immediately so the provider can check creatine kinase and renal function and stop the medication if needed. By contrast, statins are used to lower LDL (not HDL), and they are generally taken in the evening because endogenous cholesterol synthesis is higher at night.

Question 16

Prior to administering asparaginase to the 12-year-old with ALL, the nurse reviews the child’s laboratory report. Which result should prompt the nurse to notify the I-ICP before administering the asparaginase?

Accepted Answer

Answer reason: A glucose of 252 mg/dL is markedly abnormal and may indicate an acute complication that can worsen with continued therapy and may need prompt evaluation/management. By contrast, a total bilirubin of 1.2 mg/dL is only mildly elevated and not, by itself, a typical immediate hold parameter compared with severe hepatic dysfunction or pancreatitis indicators. An ANC of 1078 reflects mild-to-moderate neutropenia but asparaginase is not primarily held for myelosuppression in the same way as other chemotherapeutics; the urgent red flag here is the hyperglycemia.

Question 17

The nurse is reviewing information for the 6-month-old who is being given ranitidine. Which filldillig should the nurse identify as an adverse effect of ranitidine?

Accepted Answer

Answer reason: Hard, pellet-like stools with infrequent bowel movements is consistent with constipation and therefore matches an expected medication-related adverse effect to monitor in an infant. A heart rate of 110 bpm is within normal range for a 6-month-old and is not an adverse medication effect. Fever and persistent post-feeding spit-up suggest infection or ongoing reflux rather than a typical adverse reaction to this medication.

Question 18

The nurse is planning care for the client diagnosed with acute mania. What situation must occur prior to initiating treatment with lithium carbonate?

Accepted Answer

Answer reason: Lithium is eliminated almost entirely by the kidneys, so impaired renal function increases serum levels and markedly raises the risk of toxicity. Baseline assessment of BUN/creatinine (and ongoing monitoring) is a prerequisite to starting therapy to ensure the client can clear the drug safely. Fasting is not required to initiate lithium, and seclusion/benzodiazepine status does not determine whether lithium can be started. This reflects safety-focused medication screening for contraindications and potential harm before administration.

Question 19

The nurse is assessing the client newly started on benztropine mesylate. Which findings indicate that the client is experiencing the most common side effects of benztropine mesylate?

Accepted Answer

Answer reason: Decreased secretions and reduced GI motility commonly produce xerostomia and constipation, while pupillary dilation/cycloplegia leads to blurred vision. These are expected, frequent effects nurses should assess for and provide supportive teaching (hydration, fiber, stool softener PRN, safety with visual changes). In contrast, weight gain/sexual dysfunction are more typical of antipsychotics or antidepressants rather than anticholinergic antiparkinsonian agents.

Question 20

The adolescent is brought to the ED with wheezing, nystagmus, ataxia, and sensorimotor neuropathy after inhaling paint thinner by “bagging.” Which nursing intervention is priority?

Accepted Answer

Answer reason: Hydrocarbon/solvent inhalant abuse (e.g., paint thinner “bagging”) can rapidly precipitate life-threatening ventricular dysrhythmias (“sudden sniffing death”) via myocardial sensitization to catecholamines, making continuous cardiac monitoring an immediate priority. The neurologic findings (nystagmus, ataxia, neuropathy) suggest significant toxicity but are less likely to kill the patient in the next minutes than an abrupt malignant arrhythmia. Oxygen may be needed, but the question’s hallmark inhalant risk is dysrhythmia, and hypoxia management should occur alongside—rather than instead of—cardiac monitoring. Seizure precautions and toxicology screening are supportive/diagnostic measures that do not address the most immediate, high-mortality complication.

Question 21

A client with sickle cell disease is discussing his therapeutic regimen. Which statement by the client indicates further teaching is needed?

Accepted Answer

Answer reason:  Core teaching for sickle cell disease focuses on avoiding triggers of sickling (hypoxia, dehydration, cold exposure) and using prescribed therapies rather than self-initiated antiplatelet regimens. Routine daily low-dose aspirin is not a standard preventive measure for vaso-occlusive crises and can increase bleeding risk, especially if the client develops thrombocytopenia or needs other NSAIDs/anticoagulants. Prevention strategies more appropriately emphasize hydration, avoiding high altitude/low oxygen environments, smoking cessation, vaccinations, and provider-directed disease-modifying therapy (e.g., hydroxyurea when indicated). The other statements reflect avoidance of hypoxia (high altitude), avoiding a vasoconstrictive/hypoxic trigger (smoking), and maintaining hydration to reduce blood viscosity, which are consistent with common teaching.

Question 22

An elderly client with rheumatoid arthritis is being treated with prednisone (Deltasone). The nurse is aware that complications occurring with long-term therapy include which of the following?

Accepted Answer

Answer reason: Chronic prednisone can induce hyperglycemia and steroid-induced diabetes, especially in older adults with reduced metabolic reserve. It also accelerates osteoporosis, increasing fracture risk, making bone protection and monitoring key nursing considerations. The cancer option is not a typical direct complication of prednisone therapy, and weight loss is opposite of the common steroid effect of weight gain and fat redistribution.

Question 23

One hour after receiving pyridostigmine bromide (Mestinon), a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the physician and prepares to administer which medication?

Accepted Answer

Answer reason: Symptoms occurring shortly after dosing suggest a cholinergic crisis/overmedication rather than undertreatment, so an antimuscarinic is indicated to dry secretions and reduce bronchospasm. Edrophonium is used diagnostically to help differentiate myasthenic versus cholinergic crisis but is not the immediate bedside treatment for severe muscarinic symptoms. Giving more pyridostigmine would worsen the muscarinic effects, and acyclovir is unrelated to this medication adverse effect pattern.

Question 24

A nurse is giving discharge instructions to the parents of a child with Kawasaki disease. Which statement by the parents shows an understanding of the treatment plan?

Accepted Answer

Answer reason:  Kawasaki disease treatment commonly includes antiplatelet-dose aspirin after the acute phase, which increases bleeding risk due to platelet inhibition. Using a soft-bristled toothbrush helps reduce gingival trauma and minimizes mucosal bleeding while the child is on aspirin therapy. Black, tarry stools would be a warning sign of gastrointestinal bleeding and require prompt evaluation rather than being considered normal. Return to vigorous sports may be restricted depending on coronary artery involvement, so a blanket plan to play soccer next week is not reliably safe.

Question 25

A client with a diagnosis of schizophrenia is receiving an antipsychotic medication. His physician has just prescribed benztropine (Cogentin). The nurse determines that this medication was most likely prescribed which adverse reaction?

Accepted Answer

Answer reason: Acute dystonia is an early, potentially urgent EPS presenting with sustained muscle contractions (e.g., torticollis, jaw spasm, oculogyric crisis, laryngospasm) and responds rapidly to benztropine or diphenhydramine. Tardive dyskinesia is typically late-onset and is not reliably treated with anticholinergics and may worsen with them. Orthostatic hypotension is managed by dose adjustment and safety measures rather than benztropine, and hypertensive crisis is classically linked to MAOI–tyramine interactions, not antipsychotic EPS.

Question 26

The client diagnosed with osteoarthritis has been self-medicating with high doses of aspirin for the pain. Which comment by the client would warrant further evaluation by the nurse?

Accepted Answer

Answer reason: High-dose salicylate use can cause toxicity, with tinnitus being an early warning sign that serum levels may be excessive. This finding warrants prompt assessment of dosing, duration, other salicylate/NSAID use, and associated symptoms such as dizziness, nausea, hyperventilation, or confusion. Taking aspirin with food is a common strategy to reduce GI upset and is not itself alarming. Although gum bleeding can indicate platelet dysfunction and should be reported, tinnitus is a more specific early indicator of aspirin toxicity requiring immediate evaluation and possible dose adjustment or discontinuation.

Question 27

A 32-year-old female client who is 5 months pregnant is diagnosed with pelvic inflammatory disease and given a prescription for metronidazole (Flagyl). Which substance should be avoided in this client in order to prevent an interaction with Flagyl?

Accepted Answer

Answer reason: Metronidazole can inhibit aldehyde dehydrogenase and precipitate a disulfiram-like reaction when combined with ethanol. This interaction can cause flushing, throbbing headache, nausea/vomiting, abdominal cramping, and tachycardia, which is a key safety teaching point for clients taking this medication. Clients should avoid all alcoholic beverages and hidden sources of alcohol (e.g., some cough syrups, mouthwashes) during therapy and for at least 48–72 hours after the last dose. The other listed substances are not the classic, high-yield interaction that produces an acute, predictable adverse reaction with metronidazole.

Question 28

The nurse is concerned that an elderly home care client may overdose on prescribed opioid analgesics. Which set of symptoms indicate the classic triad of opiate overdose?

Accepted Answer

Answer reason: Opioid toxicity classically causes central nervous system depression and suppression of the medullary respiratory drive, producing hypoventilation that can rapidly lead to hypoxia and death. The hallmark pupil finding is pinpoint pupils (miosis) from parasympathetic dominance, paired with respiratory depression and decreased level of consciousness/coma. Options describing hyperactivity, hypertension, hallucinations, or Kussmaul respirations point toward other toxidromes or metabolic acidosis patterns rather than opioid overdose. Dilated pupils and seizures are not the typical triad for opioids and suggest alternate causes such as stimulant toxicity or other neurologic pathology.

Question 29

A client has just started treatment with rifampin for tuberculosis. Which statement indicates the client has a good understanding of his medication?

Accepted Answer

Answer reason:  Rifampin commonly causes harmless orange-red discoloration of body fluids (urine, sweat, tears), and recognizing this expected effect indicates accurate medication teaching was understood. This awareness helps prevent unnecessary alarm and supports adherence to the multidrug TB regimen. Avoiding all gatherings for 6 months is not the key medication-specific teaching, and infectiousness typically decreases after effective therapy but does not eliminate the need for respiratory hygiene early in treatment. Throwing away utensils is unnecessary because TB is transmitted via airborne droplets, not via fomites like forks and spoons.

Question 30

The HCP prescribed atorvastatin, (Lipitor), an HMG-CoA reductase inhibitor. Which teaching intervention should the nurse include when discussing this medication?

Accepted Answer

Answer reason: Statins can cause myopathy ranging from mild myalgias to rare rhabdomyolysis, so patient teaching must emphasize recognizing and reporting new unexplained muscle pain, tenderness, or weakness. This education supports early detection of potentially serious toxicity and prompt evaluation (e.g., creatine kinase and renal function) if symptoms occur. Timing the dose in the evening is more relevant to shorter-acting statins; atorvastatin has a longer half-life and may be taken any time, so that teaching is less essential. Daily self-checking cholesterol is inappropriate because lipid levels are monitored periodically through laboratory testing, not home devices.

Question 31

The nurse is providing information to a client taking metronidazole (Flagyl). What is the most important information for the nurse to include?

Accepted Answer

Answer reason: Metronidazole can trigger a disulfiram-like reaction when combined with ethanol, leading to significant GI distress and systemic symptoms that can be severe and dangerous. This is a high-priority teaching point because it is preventable and requires clear avoidance guidance (including products that may contain alcohol). Urine discoloration can occur but is not safety-critical compared with avoiding alcohol. Breathlessness/cough and palpitations are not expected common teaching points for this medication and would distract from the key contraindicated interaction.

Question 32

The cardiac monitor of the client diagnosed with Prinzmetal’s angina shows a prolonged PR interval of 0.32 seconds- Which prescribed medication should the nurse question administering to the client?

Accepted Answer

Answer reason: 32 seconds indicates significant AV conduction delay (first-degree AV block). Beta-blockers slow AV nodal conduction and can worsen existing conduction abnormalities, increasing risk of progressing to higher-degree block and symptomatic bradycardia. In Prinzmetal’s angina, therapy is typically nitrates and calcium channel blockers, which relieve coronary vasospasm rather than further depressing conduction through the AV node. Nitrates and dihydropyridine calcium channel blockers like amlodipine do not primarily worsen AV block to the same degree as AV nodal–blocking agents, making the beta-blocker the medication to question.

Question 33

The client is experiencing pain due to cancer treatment- The client tells the nurse, “Methadone has always worked well for me in the past.” Which effects of methadone should the nurse consider when administering methadone?

Accepted Answer

Answer reason: This pharmacokinetic property means monitoring must extend beyond the immediate post-dose period and dose adjustments should be cautious. A common opioid effect is hypotension rather than hypertension, making the blood pressure claim less consistent with expected pharmacodynamics. It also does not produce problematic active metabolites in the way morphine does, so the “active metabolites” statement is inaccurate for the key safety consideration.

Question 34

The client, hospitalized with an exacerbation of SLE, is to receive methylprednisolone 20 mg IV q8h. Which intervention should the nurse anticipate being included in the client's plan of care?

Accepted Answer

Answer reason: Systemic corticosteroids can induce hyperglycemia by increasing insulin resistance and hepatic glucose production, and this effect can occur even in patients without diabetes. Scheduled bedside glucose monitoring allows early detection and treatment to prevent complications such as dehydration, infection risk, and poor wound healing. In an inpatient receiving IV methylprednisolone every 8 hours, glucose elevations may be persistent across the day, making pre-meal and bedtime checks appropriate. The other options are not routine preventive measures specific to corticosteroid therapy; for example, diphenhydramine premedication is more consistent with preventing infusion or allergic reactions to certain biologics rather than steroids.

Question 35

A 6-day-old infant is to receive nystatin to treat adherent white patches on the tongue, palate, and inner aspect of the cheeks. Which most important information should the nurse teach the parent about nystatin?

Accepted Answer

Answer reason: Nystatin is a topical/oral antifungal commonly used for neonatal oral candidiasis, and parent teaching should emphasize key safety information, including expected adverse effects and what to report. Gastrointestinal upset can occur (especially if some medication is swallowed), so caregivers should monitor for vomiting or diarrhea that could contribute to dehydration in a newborn. Option C is inappropriate because a 6-day-old cannot follow “swish and swallow” instructions; instead, medication is applied to oral mucosa after feeds. Options A and B are less critical: observing improvement is expected, and contact dermatitis is not the primary concern for oral nystatin administration.

Question 36

Benazepril is added to the antihypertensive medication regimen of an African American client who is 30 weeks pregnant. Which nursing intervention is most important?

Accepted Answer

Answer reason: ACE inhibitors are contraindicated in pregnancy, especially in the 2nd and 3rd trimesters, because they can cause fetal renal dysgenesis leading to oligohydramnios, neonatal renal failure, and other serious fetotoxic effects. At 30 weeks’ gestation, the priority nursing action is to prevent exposure by holding the medication and immediately notifying the prescriber for a safer alternative. Monitoring effectiveness in lowering blood pressure is irrelevant if the drug is unsafe for the fetus. While hyperkalemia is a known risk of ACE inhibitors, addressing the contraindication in pregnancy takes precedence over lab monitoring.

Question 37

The nurse is teaching the parent of the 3-year-old being treated with vincristine sulfate for Wilms’ tumor. The nurse should inform the parents to immediately notify the HCP of which most significant adverse effect?

Accepted Answer

Answer reason: Vincristine’s dose-limiting toxicity is neurotoxicity from peripheral and autonomic nerve injury, which can progress and become function-limiting or dangerous. New paresthesias suggest peripheral neuropathy, and dysphagia can indicate cranial or autonomic involvement that increases risk for aspiration and requires prompt evaluation and possible dose adjustment/holding therapy. In contrast, alopecia and diarrhea are generally expected, non–life-threatening chemotherapy effects that are usually managed supportively rather than requiring urgent provider notification. Depression may occur in cancer care but is not a hallmark acute toxicity requiring immediate action related to this medication.

Question 38

While the nurse is completing the assessment of the child with Reye’s syndrome, the parent states that multiple OTC medications were given before hospitalization to treat the child’s influenza symptoms. Which medication stated by the parent is most important for the nurse to report to the HCP?

Accepted Answer

Answer reason: This product contains a salicylate (subsalicylate), making it the most clinically urgent OTC medication to report due to a key contraindication in children with viral symptoms. Prompt reporting supports identifying a likely precipitating agent and reinforcing avoidance of salicylate-containing products. In contrast, acetaminophen is generally the preferred antipyretic/analgesic alternative in children when dosed appropriately and is not linked to Reye’s syndrome.

Question 39

The client is newly prescribed tramadol hydrochloride for chronic pain. The client is also taking fluoxetine 40 mg daily for depression. Which nursing action is most important?

Accepted Answer

Answer reason: Tramadol has serotonergic activity and, when combined with an SSRI such as fluoxetine, increases the risk of serotonin toxicity, which can rapidly become life-threatening. The priority nursing action is vigilant assessment for early manifestations such as agitation/confusion, diaphoresis, hyperreflexia/clonus, tremor, tachycardia, hypertension, and hyperthermia so that the medications can be held and the prescriber notified promptly. Increasing the SSRI dose would further raise serotonin levels and risk, making it unsafe. Advice about fluids or taking with food may be helpful for general side effects but does not address the highest-risk interaction.

Question 40

The newly hospitalized client admits using heroin 8 hours ago. Which assessment findings, if observed in the client, should the nurse associate with heroin withdrawal?

Accepted Answer

Answer reason: After short-acting opioids like heroin, withdrawal can begin within hours, so symptoms at 8 hours are expected. Dilated pupils, diaphoresis, and dysphoria/restlessness are classic withdrawal findings. In contrast, pinpoint pupils, constipation, and urinary retention are typical of opioid intoxication, not withdrawal.

Question 41

A client is being discharged home with a prescription for skeletal muscle relaxants. What is the most important information for the nurse to tell the client?

Accepted Answer

Answer reason: Skeletal muscle relaxants commonly depress the central nervous system, causing sedation, slowed reaction time, and dizziness. The highest-priority discharge teaching is injury prevention, especially avoiding driving, operating machinery, and other tasks requiring full alertness until the client knows how the medication affects them. Doubling a missed dose is unsafe and increases risk of excessive CNS depression and falls. Many cough/cold products contain sedating antihistamines or other CNS depressants, which can intensify these effects and should only be taken with guidance.

Question 42

A client with multiple sclerosis (MS) is started on 20 mg of glatiramer (Copaxone) subcutaneously daily. Immediately after the injection, the client experiences flushing and chest pain. What is the most appropriate nursing intervention?

Accepted Answer

Answer reason: Glatiramer can cause an immediate post-injection reaction characterized by flushing, chest tightness/pain, palpitations, anxiety, and dyspnea that is typically transient and self-limited. The safest initial nursing response is close assessment and monitoring of airway, breathing, circulation, vital signs, and symptom progression to confirm it resolves promptly. Escalation (oxygen, provider notification, emergency response) is indicated if symptoms persist, worsen, or suggest anaphylaxis/true cardiopulmonary compromise (e.g., hypotension, wheeze/stridor, hypoxia, altered LOC). Calling a code is premature in a stable patient with a known brief reaction pattern, while simply notifying the provider without immediate monitoring misses the priority of ongoing assessment for deterioration.

Question 43

After a nurse instills atropine drops into both eyes for a client undergoing an ophthalmic examination, which instruction should be given to the client?

Accepted Answer

Answer reason: Atropine is an anticholinergic (muscarinic antagonist) that causes mydriasis and cycloplegia, reducing the eye’s ability to constrict the pupil and accommodate. This leads to photophobia and glare sensitivity, so protective eyewear is needed in bright environments to improve comfort and safety. The expected pupil change is dilation rather than constriction, making guidance about unusually small pupils incorrect. The blink reflex is not the primary effect of topical atropine in this context; the key safety issue is light sensitivity and temporarily impaired near vision.

Question 44

The parents of a 2-year-old child who has been started on rifampin (Rifadin) after testing positive for tuberculosis ask the nurse if there is any important information they need to know about the medication. What is the most important information for the nurse to provide?

Accepted Answer

Answer reason: Teaching this prevents alarm and supports adherence, which is critical for effective tuberculosis treatment. The other choices do not reflect expected counseling points: rifampin is more associated with hepatotoxicity (potentially elevated liver enzymes), not decreased liver enzymes. It also does not typically cause hyperactivity, and bilirubin changes are not a key routine teaching point compared with the predictable secretion discoloration.

Question 45

The nurse starts cefazolin sodium 500 mg intravenously for the client. Five minutes later, the nurse stops the infusion when the client states, “My throat feels like it is closing shut.” Which intervention should the nurse implement next?

Accepted Answer

Answer reason: This presentation minutes after starting an IV antibiotic with a sensation of throat closing indicates acute anaphylaxis with impending airway compromise. First-line treatment is immediate epinephrine to reverse upper-airway edema, bronchospasm, and hypotension, with an antihistamine as adjunct therapy to reduce histamine-mediated symptoms. Calling the provider or changing the antibiotic delays lifesaving therapy and does not address the emergent airway and circulatory threat. A medic alert bracelet is appropriate later for prevention education, not as the next intervention in an acute reaction.

Question 46

The nurse administers promethazine hydrochloride (Phenergan) intravenously to a client. Which action by the nurse is appropriate when the client complains of pain in the arm being used for the intravenous site?

Accepted Answer

Answer reason: IV promethazine is a known vesicant/irritant and can cause severe tissue injury with infiltration or extravasation. New pain or burning at the IV site is an early warning sign of phlebitis or extravasation, so the safest immediate nursing action is to stop the infusion to prevent further damage. Continuing (even more slowly) or dismissing the symptom risks worsening necrosis and neurovascular injury. After stopping, the nurse should assess IV patency and the site, follow facility protocol for suspected extravasation, and notify the provider/pharmacy as indicated.

Question 47

The nurse knows a true statement regarding intra-arterial catheters is?

Accepted Answer

Answer reason: Arterial catheter insertion carries a risk of mechanical vascular injury because arteries have higher pressure and a thicker wall, and trauma during cannulation can damage the vessel layers. This makes dissection, thrombosis/occlusion, hematoma, and distal ischemia clinically relevant complications nurses must monitor for after placement. Intra-arterial catheters are real devices primarily used for continuous blood pressure monitoring and frequent arterial blood sampling, not routine medication delivery such as chemotherapy. They are also not “always” placed in the femoral artery; radial placement is common when appropriate collateral circulation exists.

Question 48

A client diagnosed with bipolar disease is receiving a maintenance dosage of lithium carbonate (Lithobid). His wife calls the community mental health nurse to report that her husband is hyperactive and hyperverbal. Which intervention would be most important to implement?

Accepted Answer

Answer reason: Hyperactivity and pressured/rapid speech are consistent with manic symptom recurrence, which can occur if serum levels are too low or adherence is poor. Checking a serum level is the most direct, high-yield intervention that guides immediate medication adjustments and safety planning. A mental status exam is useful but does not address the key medication-related risk, and ED evaluation or admission is typically reserved for severe impairment, danger to self/others, or suspected significant toxicity.

Question 49

The nurse and occupational therapist are planning an outdoor volleyball game and picnic for eight mental health clients. What action should the nurse take for the two clients taking nortriptyline (Pamelor) for depression?

Accepted Answer

Answer reason: Tricyclic antidepressants such as nortriptyline commonly cause anticholinergic and alpha-1–blocking effects, leading to orthostatic hypotension and dizziness. During outdoor activity and a picnic, clients are at higher risk for falls, fainting, and injury if blood pressure drops with position changes or dehydration. The safest nursing action is to anticipate this adverse effect and plan supervision, gradual position changes, and hydration/rest as needed. Photosensitivity precautions are more characteristic of certain other psychotropics (e.g., some antipsychotics), and withholding a scheduled antidepressant dose is not a routine safety measure and can worsen symptom control.

Question 50

The home health nurse is perforating a follow-up visit for the client diagnosed with chronic hepatitis B. The client is being treated with interferon alpha-2b. Which client comment requires further assessment by the nurse?

Accepted Answer

Answer reason:  Interferon alpha-2b can cause bone marrow suppression leading to thrombocytopenia, which increases bleeding and bruising risk and warrants prompt evaluation. Easy bruising suggests impaired clotting/platelet function and may require checking CBC/platelets and assessing for other bleeding (petechiae, gums, stool). In contrast, fatigue and flu-like symptoms are common expected effects, and avoiding crowds reflects appropriate infection-risk precautions when leukopenia is possible. Mild weight gain is less specific and, without other signs of fluid overload or worsening liver failure, is not as immediately concerning as bleeding manifestations.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Adverse Effects-Contraindications NCLEX Practice Test

Continue Learning