Question 1

The Chemotherapeutic drugs causes?

Accepted Answer

Answer reason: Many chemotherapeutic agents cause dose-limiting bone marrow suppression, which can lead to aplastic anemia with pancytopenia. This cytotoxic effect directly damages rapidly dividing hematopoietic cells. While neutropenia from this can predispose to infections, infections are a complication rather than the primary drug effect. Hemophilia is an inherited coagulation disorder, and therapy-related leukemias are classically AML/MDS rather than ALL, making aplastic anemia the best answer.

Question 2

A newly admit client has started taking bupropion (Wellbutrin). The nurse monitors in which of the following side effects that would indicate an overdosage of the medication?

Accepted Answer

Answer reason: Bupropion lowers the seizure threshold, and the risk of seizures increases in a dose-dependent manner; overdose is strongly associated with seizures. Headache, dizziness, and constipation are relatively common adverse effects but do not specifically signal toxicity. Monitoring for new-onset seizures or seizure activity is critical when overdose is suspected.

Question 3

Cely with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?

Accepted Answer

Answer reason: Lithium is handled by the kidneys similarly to sodium; when serum sodium is low, the kidneys reabsorb more lithium, raising serum lithium levels and risk of toxicity. Therefore, sodium balance must be assessed and maintained prior to dosing. Monitoring sodium helps guide safe administration along with renal monitoring.

Question 4

A patient with atrial fibrillation is being treated with amiodarone. Which adverse effect should the nurse monitor for?

Accepted Answer

Answer reason: Amiodarone is strongly associated with pulmonary toxicity, including interstitial pneumonitis and pulmonary fibrosis. Patients may present with nonproductive cough, dyspnea, fever, and diffuse pulmonary infiltrates. Baseline and periodic chest X-rays and pulmonary function testing are recommended. Renal dysfunction and hypoglycemia are not typical toxicities, and while hypotension may occur with IV dosing, pulmonary toxicity is the major adverse effect requiring ongoing monitoring.

Question 5

A patient with heart failure is prescribed furosemide. What electrolyte imbalance should the nurse monitor for?

Accepted Answer

Answer reason: Furosemide is a loop diuretic that inhibits the Na-K-2Cl transporter in the thick ascending limb, causing marked diuresis with increased urinary potassium loss. This places patients at high risk for hypokalemia, which can lead to arrhythmias and muscle weakness. Hyperkalemia is not expected, and sodium abnormalities are less characteristic than potassium wasting. Therefore, potassium levels should be closely monitored.

Question 6

A patient with atrial fibrillation is receiving warfarin. Which dietary instructions should the nurse provide?

Accepted Answer

Answer reason: Warfarin’s effect is antagonized by vitamin K, so large fluctuations in vitamin K intake can cause INR instability with bleeding or clotting risk. Patients should keep vitamin K consumption consistent rather than eliminate these foods. Avoiding all leafy greens is unnecessary and can impair nutrition. Vitamin C and high-protein intake are not clinically relevant to warfarin’s anticoagulant effect.

Question 7

Which electrolyte imbalance is most common with furosemide?

Accepted Answer

Answer reason: Furosemide is a loop diuretic that blocks the Na-K-2Cl cotransporter in the thick ascending limb, increasing urinary losses of sodium and water along with potassium. This potassium wasting commonly produces hypokalemia, which may lead to muscle weakness and cardiac arrhythmias if not monitored. While furosemide can also lower calcium and magnesium, hypokalemia is the most frequent clinically significant electrolyte disturbance.

Question 8

A heart failure patient is being cared for by the nurse. Which medication should the nurse clarify with the primary healthcare provider (PHCP)?

Accepted Answer

Answer reason: Prednisone (a systemic corticosteroid) can cause sodium and water retention, increasing intravascular volume and potentially worsening heart failure with edema, weight gain, and elevated blood pressure. In a patient with HF, this medication warrants clarification to ensure there is a strong indication and that monitoring/mitigation (e.g., lowest effective dose, diuretic adjustment) is planned. In contrast, lisinopril (ACE inhibitor) and carvedilol (beta-blocker) are guideline-directed therapies that improve outcomes in HFrEF, and hydralazine can be used as an afterload reducer (often with nitrates) when indicated.

Question 9

The nurse is giving instructions to the client who has a new prescription for phenelzine. What should the nurse instruct the client to avoid eating?

Accepted Answer

Answer reason: Phenelzine is a monoamine oxidase inhibitor (MAOI), which requires avoiding tyramine-rich foods to prevent a potentially life-threatening hypertensive crisis. Cured/aged/fermented meats (e.g., pepperoni, salami) are high in tyramine and are a classic contraindication with MAOIs. Cooked fresh chicken is not high in tyramine. While some dairy products can contain tyramine when aged (e.g., aged cheeses), pepperoni is the clearest high-risk option listed.

Question 10

A client is receiving alteplase (tPA) for an acute myocardial infarction and develops severe bleeding. What is the nurse’s priority action?

Accepted Answer

Answer reason: Alteplase (tPA) is a thrombolytic that increases fibrinolysis and can cause life-threatening hemorrhage. With severe bleeding, the priority is to stop the medication immediately to prevent further clot breakdown, then promptly notify the provider for additional orders (e.g., blood products, antifibrinolytic therapy, diagnostic evaluation). Protamine reverses heparin (not tPA), and vitamin K reverses warfarin; dialysis does not address thrombolytic-associated bleeding.

Question 11

Which sign indicates digoxin toxicity?

Accepted Answer

Answer reason: Digoxin toxicity classically presents with gastrointestinal symptoms (e.g., nausea/vomiting), cardiac dysrhythmias (often bradycardia or AV block), and characteristic visual changes such as blurred vision or yellow-green halos. Among the options, visual disturbances are the most specific and well-known indicator of digoxin toxicity. Tachycardia and hypertension are not typical hallmark findings, and hyperglycemia is unrelated. Therefore, visual disturbances best indicate digoxin toxicity.

Question 12

A patient with hypertension is prescribed lisinopril. Which of the following should the nurse monitor for during the course of treatment?

Accepted Answer

Answer reason: Lisinopril is an ACE inhibitor that decreases aldosterone secretion, which reduces renal potassium excretion and can lead to hyperkalemia. This risk is higher in patients with renal impairment and in those taking potassium supplements or potassium-sparing diuretics. Therefore the nurse should monitor serum potassium (and renal function) during therapy. The other listed electrolyte/glucose abnormalities are not the typical monitoring priority specific to ACE inhibitors.

Question 13

Which symptom is an early sign of aspirin toxicity?

Accepted Answer

Answer reason: An early and classic manifestation of salicylate (aspirin) toxicity is tinnitus (ringing in the ears), often accompanied by hearing changes. This occurs before more severe toxicity signs such as hyperventilation, metabolic acidosis, confusion, and hyperthermia. Fever can occur in severe poisoning but is not typically an early sign. Drowsiness and tachycardia are nonspecific and less characteristic than tinnitus for early salicylate toxicity.

Question 14

Your patient is taking Methotrexate for her rheumatoid arthritis. Which lab would you monitor closely?

Accepted Answer

Answer reason: Methotrexate is an antimetabolite DMARD that can cause bone marrow suppression, increasing risk for leukopenia and serious infection. Monitoring the WBC (as part of a CBC) helps detect myelosuppression early so the medication can be held or adjusted. INR monitoring is primarily for warfarin therapy, and potassium is not a routine toxicity marker for methotrexate. While hemoglobin can drop with marrow suppression, WBC changes are the most critical early safety signal for infection risk.

Question 15

A patient receiving nitroprusside (Nitropress) for hypertensive crisis develops confusion, tinnitus, and metabolic acidosis. Which action should the nurse take first?

Accepted Answer

Answer reason: Confusion, tinnitus, and metabolic acidosis in a patient on nitroprusside are classic findings of cyanide (or thiocyanate) toxicity, a life-threatening adverse drug reaction. The priority nursing action is to stop the offending infusion to prevent further toxin generation and worsening acidosis. Supportive measures and antidotal therapy (e.g., hydroxocobalamin or sodium thiosulfate) are then initiated per provider/rapid response orders, but stopping the infusion is the first step. Sodium bicarbonate alone does not treat the cause, and furosemide is not indicated for this toxicity.

Question 16

A patient with atrial fibrillation on warfarin (Coumadin) presents with INR of 5.8 and reports gum bleeding. What should the nurse anticipate administering?

Accepted Answer

Answer reason: An INR of 5.8 with active bleeding (gum bleeding) indicates excessive anticoagulation from warfarin. The specific reversal agent for warfarin is vitamin K (phytonadione), which restores hepatic synthesis of vitamin K–dependent clotting factors (II, VII, IX, X). Protamine reverses heparin, and desmopressin is used for platelet dysfunction/von Willebrand disease. Fresh frozen plasma may be used for urgent/life-threatening bleeding, but the key anticipated antidote for warfarin toxicity is vitamin K.

Question 17

The nurse is discharging a patient with a new patient for ranitidine (Zantac). Which information would be important to include in the discharge teaching?

Accepted Answer

Answer reason: Ranitidine (an H2-receptor antagonist) can cause central nervous system effects such as restlessness, confusion, or dizziness, particularly in older adults or those with renal impairment, so this is an important discharge teaching point. Aspirin coadministration is not a key routine teaching item and may increase GI irritation/bleeding risk depending on the patient’s condition. TTP is classically associated with some antiplatelet agents (e.g., ticlopidine/clopidogrel), not ranitidine. Iron deficiency anemia is not a typical adverse effect of ranitidine.

Question 18

A nurse is reviewing discharge instructions for a client taking warfarin. Which statement indicates the client needs further teaching?

Accepted Answer

Answer reason: Warfarin is an anticoagulant, and aspirin (and many NSAIDs) can increase bleeding risk by inhibiting platelet function and irritating the GI mucosa. Combining aspirin with warfarin raises the risk of serious bleeding and is generally avoided unless specifically prescribed. The other statements reflect correct safety teaching: consistent vitamin K intake, bleeding-prevention measures (electric razor), and avoiding activities with high injury risk.

Question 19

A nurse is administering morphine to a client with post-operative pain. What should the nurse monitor?

Accepted Answer

Answer reason: Morphine is an opioid analgesic whose most dangerous adverse effect is respiratory depression due to suppression of the brainstem respiratory drive. Therefore, monitoring respiratory rate (and overall ventilation/sedation) is the priority safety assessment after administration. While blood pressure and heart rate can change with opioids, they are less immediately life-threatening than hypoventilation. Temperature is not a primary monitoring parameter for opioid toxicity.

Question 20

A client with a history of heart failure is prescribed furosemide (Lasix). The nurse should assess the client for which potential adverse effect of this medication?

Accepted Answer

Answer reason: Furosemide is a loop diuretic that promotes sodium and water excretion, placing the client at risk for electrolyte losses including hyponatremia (and also hypokalemia). With increased diuresis, intravascular volume can also drop, but the option most directly tied to loop-diuretic electrolyte adverse effects among the choices is hyponatremia. Hyperkalemia is incorrect because furosemide causes potassium wasting, and hypoglycemia is not a typical adverse effect.

Question 21

What is the priority assessment for a patient receiving morphine?

Accepted Answer

Answer reason: Morphine (an opioid analgesic) can cause dose-dependent respiratory depression by suppressing the brainstem respiratory center. Airway and breathing take priority, so assessing respiratory rate (and overall ventilation/sedation) is the most critical safety assessment before and after administration. Pain level is important for effectiveness, but it is secondary to detecting life-threatening hypoventilation. Blood pressure and heart rate can change with opioids, but they are less immediately dangerous than respiratory depression.

Question 22

A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for?

Accepted Answer

Answer reason: Digoxin has a narrow therapeutic index, so nurses must closely monitor for early toxicity. Classic signs include gastrointestinal symptoms (anorexia, nausea/vomiting) and visual changes (blurred vision, yellow-green halos). These findings are more specific for digoxin toxicity than the other options listed. Prompt recognition is important to prevent progression to serious dysrhythmias.

Question 23

The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?

Accepted Answer

Answer reason: Amphotericin B’s dose-limiting toxicity is nephrotoxicity, which may present with renal dysfunction and urinary changes along with rising BUN/creatinine and electrolyte wasting (notably hypokalemia and hypomagnesemia). Urinary frequency can be an early clinical cue of renal irritation/dysfunction in this context and should prompt assessment of urine output trends and renal labs. Nausea is a common adverse effect and can also occur with infusion reactions, but it is not the hallmark toxicity. Vision changes and skin color changes are not typical indicators of amphotericin B toxicity compared with renal findings.

Question 24

At 0800 the RN is getting ready to administer 20 units of Regular insulin. At what time will the RN watch for hypoglycemia?

Accepted Answer

Answer reason: Regular (short-acting) insulin has an onset of about 30–60 minutes and peaks around 2–4 hours after administration; hypoglycemia risk is greatest near its peak. If given at 0800, the earliest significant blood glucose drop begins after ~0830, with peak risk roughly mid-morning. Among the listed times, 0930 (about 1.5 hours after dosing) is the best option closest to the beginning of the peak-risk window compared with 0830 (too early) and 1000 (later but not as close to the typical peak onset). Therefore, the RN should monitor most closely around 0930.

Question 25

A nurse is monitoring a client on IV heparin for DVT. Which lab value indicates the need for intervention?

Accepted Answer

Answer reason: IV unfractionated heparin is monitored primarily with the aPTT, with a typical therapeutic target about 1.5–2.5 times control (often roughly 60–80 seconds, depending on facility). An aPTT of 110 seconds is supratherapeutic and indicates increased bleeding risk, requiring intervention such as holding or reducing the infusion and notifying the provider per protocol. The other values shown (Hgb 12.5 g/dL, platelets 200,000/mm³, INR 1.0) do not, by themselves, indicate heparin toxicity or the need for immediate adjustment.

Question 26

A client is receiving gentamicin. Which assessment finding should be reported immediately?

Accepted Answer

Answer reason: Gentamicin (an aminoglycoside) can cause ototoxicity, and tinnitus (ringing in the ears) is an early warning sign that may precede irreversible hearing loss. This finding requires prompt reporting so the provider can stop or adjust the drug and evaluate serum levels. While nephrotoxicity is also a known risk, an isolated elevated BUN is less immediately specific than acute ototoxic symptoms and may have other causes. Nausea and a mild rash are generally less urgent unless severe or progressive.

Question 27

A nurse is providing discharge teaching to a client on warfarin. Which statement requires follow-up?

Accepted Answer

Answer reason: Aspirin inhibits platelet function and can significantly increase bleeding risk when taken with warfarin, so this statement indicates unsafe self-medication and requires follow-up. The other statements reflect appropriate warfarin teaching: keeping vitamin K intake consistent, monitoring INR routinely, and using a soft toothbrush to reduce bleeding from gums. Therefore, aspirin use for headaches is the key contraindicated practice among the options.

Question 28

Which medication has the potential to cause ototoxicity and nephrotoxicity?

Accepted Answer

Answer reason: Gentamicin is an aminoglycoside antibiotic classically associated with both nephrotoxicity (acute tubular injury) and ototoxicity (cochlear/vestibular damage), especially with higher trough levels and prolonged therapy. This risk is increased in older adults, dehydration, preexisting renal impairment, and when combined with other nephrotoxic drugs (e.g., vancomycin, loop diuretics). Ertapenem, clindamycin, and metronidazole are not typically linked to the characteristic combined ototoxicity and nephrotoxicity profile seen with aminoglycosides. Therefore, gentamicin is the best answer.

Question 29

A patient is prescribed digoxin. Which laboratory value should the nurse monitor closely to avoid toxicity?

Accepted Answer

Answer reason: Digoxin toxicity risk increases when serum potassium is low because hypokalemia enhances digoxin binding to the Na+/K+ ATPase, making toxic effects more likely even at therapeutic digoxin levels. Many patients taking digoxin are also on loop or thiazide diuretics, which can lower potassium and precipitate dysrhythmias. Therefore, monitoring potassium closely is essential to prevent digoxin-related cardiac toxicity.

Question 30

A client with AIDS is prescribed acyclovir (Zovirax). Nurse Miller recognizes which nursing intervention as paramount during acyclovir therapy?

Accepted Answer

Answer reason: Acyclovir can precipitate in renal tubules and cause nephrotoxicity, particularly if the client is dehydrated or receiving higher doses/IV therapy. Maintaining adequate hydration helps reduce crystalluria and supports renal clearance of the drug. Therefore, increasing fluid intake is the priority nursing intervention during acyclovir therapy. The other options do not address the most significant preventable medication-related risk.

Question 31

Nurse Evans is monitoring a client receiving amphotericin B for a systemic fungal infection. Which finding is most indicative of drug toxicity?

Accepted Answer

Answer reason: Amphotericin B is notably nephrotoxic and can cause renal impairment, which is commonly reflected by rising serum creatinine. Monitoring kidney function (creatinine/BUN, urine output, electrolytes like potassium and magnesium) is essential during therapy. Increased urine output is not typical of amphotericin B toxicity, and decreased heart rate or hypertension are not the hallmark toxic effects compared with nephrotoxicity.

Question 32

Nurse Jenna is reviewing the medical history of a client who has been prescribed Imitrex (sumatriptan succinate) for migraine headaches. Which of the following conditions in the client’s history should she report to the doctor?

Accepted Answer

Answer reason: Sumatriptan is a 5-HT1B/1D agonist that causes cranial and coronary vasoconstriction. Prinzmetal’s (variant) angina involves coronary vasospasm, and triptans can precipitate or worsen ischemia in this setting, making it a key contraindication that should be reported. Diabetes and cancer are not direct contraindications to sumatriptan, and cluster headaches may be treated with triptans rather than precluding their use.

Question 33

Nurse Williams is monitoring 6-month-old baby Ethan, who has a ventral septal defect and is on Digitalis to help manage his heart rate. During her assessment, which finding should she report to the physician?

Accepted Answer

Answer reason: Digitalis (digoxin) can cause clinically significant bradycardia, and infants normally have higher baseline heart rates than adults. A heart rate of 60 beats per minute in a 6-month-old is abnormally low and may indicate digoxin toxicity or excessive drug effect requiring prompt provider notification and possible dose adjustment/holding the medication. The other findings listed are not the most urgent or clearly abnormal for a 6-month-old in this context.

Question 34

Nurse Carter is preparing to administer diazoxide (Hyperstat) to Mrs. Johnson, who has been admitted with a hypertensive crisis. To ensure safe administration of the medication, what action should Nurse Carter take?

Accepted Answer

Answer reason: Diazoxide is a vasodilator used for hypertensive emergencies and has a key adverse effect of causing hyperglycemia by inhibiting insulin release. Therefore, monitoring blood glucose is an essential safety action during therapy to detect and manage this complication early. Trendelenburg positioning is not an administration requirement and may worsen respiratory status. Protecting from light is not a primary safety requirement for diazoxide compared with monitoring for hyperglycemia.

Question 35

Nurse Thompson is meeting with Mr. Allen, a patient who has been prescribed rosuvastatin (Crestor) after a recent blood test showed a serum cholesterol level of 275 mg/dL. Nurse Thompson needs to provide essential instructions regarding the new medication. What should she emphasize?

Accepted Answer

Answer reason: Rosuvastatin (a statin) can cause myopathy and rarely rhabdomyolysis; new muscle pain, tenderness, or weakness should be reported promptly because it may indicate serious muscle injury and need for evaluation (e.g., CK) and stopping the drug. Waiting months is not the key safety teaching; lipid changes are typically seen within weeks, with maximal effect in several weeks. Grapefruit/fruit juice interactions are classically a concern with some other statins (CYP3A4 substrates), not a recommended co-administration teaching for rosuvastatin. A baseline CBC is not routinely required; baseline liver enzymes and assessment for muscle symptoms/risk are more relevant.

Question 36

A patient is started on levothyroxine (Synthroid). Which symptom should the nurse report immediately?

Accepted Answer

Answer reason: Levothyroxine can precipitate symptoms of excessive thyroid hormone effect, including tachycardia, palpitations, and angina-like chest pain, especially if the dose is too high or if underlying coronary artery disease is present. Chest pain with palpitations may signal a potentially dangerous cardiac complication (e.g., dysrhythmia or myocardial ischemia) and requires prompt provider notification and assessment. Mild weight loss, tremor, and anxiety can occur as expected/less urgent effects early in therapy or with mild over-replacement, but they are not as immediately life-threatening as chest pain.

Question 37

Magnesium Sulfate Toxicity A preeclamptic client is receiving magnesium sulfate for seizure prophylaxis. Which finding suggests toxicity?

Accepted Answer

Answer reason: Magnesium sulfate toxicity causes central nervous system depression, with a key danger sign being respiratory depression. A respiratory rate of 10/min is abnormally low and suggests toxic magnesium levels requiring immediate action (stop infusion, assess, and prepare calcium gluconate as antidote per protocol). Urine output of 50 mL/hr indicates adequate renal clearance (toxicity risk rises with oliguria). Blood pressure 140/90 mmHg reflects preeclampsia rather than magnesium toxicity, and the reflex option is not consistent with toxicity as written.

Question 38

A nurse is caring for a client with type 2 diabetes taking metformin. Which finding requires immediate action?

Accepted Answer

Answer reason: Metformin is contraindicated or requires prompt reassessment in significant renal impairment because reduced clearance increases the risk of metformin-associated lactic acidosis. A creatinine of 2.1 mg/dL suggests impaired kidney function and warrants immediate action (holding the drug and notifying the provider, assessing eGFR and symptoms). Mild nausea is a common early side effect and is typically managed with food or dose titration. A small weight loss and an A1c of 7.2% are not urgent safety findings compared with potential metformin toxicity in renal dysfunction.

Question 39

A client is prescribed warfarin and has an INR of 5.2. What is the nurse’s priority action?

Accepted Answer

Answer reason: An INR of 5.2 is supratherapeutic for most indications and indicates a significantly increased risk for bleeding, so the priority is to prevent further anticoagulation. The nurse should hold the next warfarin dose and promptly notify the provider for further orders (e.g., dose adjustment and/or repeat INR). Administering the next dose would worsen bleeding risk, and monitoring for clotting is the opposite concern in an over-anticoagulated patient. Vitamin K is typically reserved for more severe INR elevations and/or active bleeding, so it is not the immediate nurse-driven priority based on the information given.

Question 40

What is a common side effect of a short-acting beta2 agonist such as albuterol?

Accepted Answer

Answer reason: Short-acting beta2 agonists (SABAs) like albuterol commonly cause sympathetic-type side effects, including tachycardia, palpitations, and tremor. Although they are beta2-selective, higher doses and systemic absorption can stimulate cardiac beta receptors and increase heart rate. Nausea, pallor, and hypotension are not the most typical or expected adverse effects compared with tachycardia for this drug class.

Question 41

A patient with heart failure is prescribed furosemide, which lab value should the nurse monitor most closely?

Accepted Answer

Answer reason: Furosemide is a loop diuretic that increases urinary excretion of potassium, placing the patient at high risk for hypokalemia. Low potassium can precipitate dangerous dysrhythmias, especially in heart failure patients who may also be on digoxin or other cardiac medications. Therefore, potassium should be monitored most closely to detect and treat electrolyte depletion early. Hemoglobin is not directly affected, and sodium/calcium changes can occur but are typically less immediately dangerous than potassium loss.

Question 42

Which diagnostic test must be performed before prescribing amiodarone in a patient with respiratory symptoms?

Accepted Answer

Answer reason: Amiodarone can cause pulmonary toxicity (e.g., interstitial pneumonitis/fibrosis), which may worsen or mimic existing respiratory symptoms. Baseline pulmonary assessment with pulmonary function testing (often including DLCO) helps identify pre-existing impairment and provides a reference if dyspnea or cough progresses after starting therapy. While ECG monitoring and liver tests are also important for amiodarone safety, the question specifically emphasizes respiratory symptoms, making pulmonary function testing the most directly indicated pre-prescribing diagnostic test among the options.

Question 43

Which of the following medications can cause teeth discoloration?

Accepted Answer

Answer reason: Tetracyclines can chelate calcium and become incorporated into developing teeth and bone, leading to permanent yellow-brown tooth discoloration and enamel hypoplasia. This risk is greatest with exposure during pregnancy (especially after mid-gestation) and in children younger than about 8 years while teeth are developing. Acetaminophen, furosemide, and omeprazole are not classically associated with permanent tooth staining. Therefore, tetracycline is the best answer.

Question 44

A patient has digoxin toxicity. Which of the following would this patient most likely have?

Accepted Answer

Answer reason: Digoxin toxicity classically causes visual disturbances, particularly xanthopsia (yellow vision) and yellow halos around lights/objects. These visual changes occur along with other toxicity findings such as nausea/vomiting and dysrhythmias, making yellow halos a hallmark sign. The other halo colors listed are not the typical presentation associated with digoxin toxicity.

Question 45

The nurse is caring for a three-year-old who is receiving digoxin for congestive heart failure. Which of the following manifestations is an early sign of digoxin toxicity?

Accepted Answer

Answer reason: Early digoxin toxicity commonly presents with gastrointestinal symptoms, especially nausea and vomiting, and this is often the first clue in pediatric patients. Tachycardia is not typical as an early finding; digoxin more often causes bradycardia and dysrhythmias as toxicity progresses. Dizziness can occur but is less characteristic and less reliable than GI upset for early detection. Failure to thrive is a chronic, nonspecific finding and is not an early sign of acute digoxin toxicity.

Question 46

A nurse is caring for a patient with heart failure who has been prescribed furosemide (Lasix). Which assessment finding should be reported to the healthcare provider immediately?

Accepted Answer

Answer reason: Furosemide is a loop diuretic that can cause significant potassium wasting, placing the patient at risk for symptomatic hypokalemia and life-threatening dysrhythmias. A potassium of 2.9 mEq/L is abnormally low and warrants immediate provider notification for prompt replacement and monitoring (e.g., ECG). Mild ankle edema can be expected in heart failure and may improve with diuresis. BP 138/86 mmHg and urine output of 1,200 mL/24 hr are not as immediately dangerous as severe hypokalemia in a patient on a loop diuretic.

Question 47

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

Accepted Answer

Answer reason: Cimetidine (an H2-receptor antagonist) can cross the blood-brain barrier and is associated with CNS adverse effects, especially in older adults and those with renal impairment. The most commonly noted CNS effect in this population is confusion (often presenting as acute delirium). Hallucinations and tremors can occur but are less frequent than confusion in typical nursing test references. Monitoring mental status changes and safety is therefore a priority.

Question 48

Which laboratory result would indicate the need for immediate intervention in a patient taking warfarin?

Accepted Answer

Answer reason: Warfarin therapy is monitored with INR, and supratherapeutic values significantly increase bleeding risk. For most indications, the therapeutic INR range is about 2.0–3.0 (sometimes 2.5–3.5 for certain mechanical valves), so 2.5 is typically therapeutic and 3.2 may be only mildly elevated depending on indication. An INR of 5.0 is markedly elevated and commonly requires immediate clinical action (e.g., holding warfarin, assessing for bleeding, and considering vitamin K per protocol). Therefore, INR 5.0 indicates the most urgent need for intervention.

Question 49

A nurse is caring for a 55-year-old patient with atrial fibrillation who is receiving warfarin (Coumadin). Which assessment finding requires the nurse to take immediate action?

Accepted Answer

Answer reason: Warfarin increases bleeding risk, and multiple large bruises can indicate clinically significant bleeding or excessive anticoagulation requiring prompt assessment and provider notification. An INR of 2.5 is within the typical therapeutic range for atrial fibrillation (generally 2.0–3.0) and is not an emergency finding by itself. A mild headache is nonspecific and warrants evaluation, but visible extensive bruising is a clearer sign of bleeding complication needing immediate action. Blood pressure 128/78 mmHg is within normal limits and does not require urgent intervention.

Question 50

A nurse is caring for a client in preterm labor who is receiving terbutaline to suppress uterine contractions. Which maternal finding should the nurse report to the healthcare provider immediately?

Accepted Answer

Answer reason: Terbutaline is a beta-adrenergic agonist tocolytic that can cause significant maternal cardiovascular adverse effects, especially tachycardia and dysrhythmias. A maternal heart rate of 140 bpm is a concerning, potentially dangerous medication effect that warrants immediate provider notification and possible discontinuation. Maternal tremors are a common expected side effect, and a temperature of 99°F is not a fever. A blood pressure of 100/68 mmHg is generally acceptable in pregnancy and is not the most urgent finding compared with marked tachycardia.

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