1. A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify
which of the following findings as a manifestation of fluid volume excess?
a. Decreased bowel sounds
b. Distended neck
...
1. A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify
which of the following findings as a manifestation of fluid volume excess?
a. Decreased bowel sounds
b. Distended neck veins
c. Bilateral muscle weakness
d. Thread pulse
2. A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed
hypertonic solution. Which of the following findings should indicate to the nurse that the
treatment is effective?
a. Absent Chvostek’s sign
b. Improved cognition
c. Decreased vomiting
d. Cardiac arrhythmias absent
3. A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal patch.
Which of the following instructions should the nurse include?
a. “Discontinue the patch if you experience a headache.”
b. “Apply a new patch if you have chest pain.”
c. “Cover the patch with dry gauze when taking a shower.”
d. “Remove the patch prior to going to bed.”
4. A nurse is reviewing he laboratory results of a client who has a prescription for sodium
polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should the nurse report to
the provider?
a. Creatinine 0.72 mg/dL
b. Sodium 138 mEq/L
c. Magnesium 2 mEq/L
d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassium level greater than 5.0 mEq/L)
increases the client risk for fatal cardiac dysrhythmias. Kayexalate is used to decrease the
serum potassium level, so the PN should monitor the client's serum potassium level
5. A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of
the following outcomes indicates that the client is adhering to the medication regimen?
a. The client has a negative sputum culture
b. The client tests negative for HIV
c. The client has a positive purified protein derivative test
d. The client’s liver function test results are within the expected reference range
6. A client is caring for a client who develops an anaphylactic reaction to IV administration. After
assessing the client’s respiratory status and stopping the medication infusion. Which of the
following actions should the nurse take next?
a. Replace the infusion with 0.9% sodium chloride
b. Give diphenhydramine IM
c. Elevate the client’s legs and feet
d. Administer epinephrine IM
7. A nurse is caring for a client who is taking sertraline and reports a desire to begin taking
supplements. Which of the following supplements should the nurse advise the client to avoid?
a. St. John’s Wort
b. Ginger root
c. Black cohosh
d. Coenzyme Q10
8. A nurse is caring for a client who has heart failure and a new prescription for lisinopril. For which
of the following adverse effects should the nurse monitor when administering lisinopril?
a. Bradycardia
b. Hypokalemia
c. Tinnitus
d. Hypotension
9. *A nurse is assessing a client who is receiving heparin IV continuous IV. The client has an PPT of
90 seconds. They should monitor the client for which of the following changes in their vital
signs?
a. Decreased temperature
b. Increased pulse rate
c. Decreased respiratory rate
d. Increased blood pressure
10. A nurse is preparing to administer medication to a client and discovers a medication error. The
nurse should recognize that which of the following staff members is responsible for completing
an incident report?
a. The quality improvement committee
b. The nurse who identifies the error
c. The nurse who caused the error
d. The charge nurse
11. A nurse is planning care for a client who is receiving morphine via continuous epidural infusion.
The nurse should monitor the client for which of the following?
a. Pruritus – Sign of allergic reaction to morphine
b. Cough
c. Tachypnea
d. Gastric bleeding
12. A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the
nurse should take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.)
a. Obtain the client’s apical heart rate
b. Remove the medication from the dispensing system
c. Open the medication package
d. Compare the client’s wristband to the medication administration record
e. Document administration of the medication
13. A nurse is reviewing the medical record of an adult client who has a fever and a prescription for
acetaminophen. Which of the following findings should the nurse identify as a contraindication
for receiving this medication?
a. Alcohol use disorder
b. Chronic kidney disease
c. Hepatitis B vaccine within the last week
d. Diabetes mellitus
14. A home health nurse is visiting a client who has heart failure and a prescription for furosemide.
The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last visit 2 days ago. Which
of the following actions should the nurse take first?
a. Encourage the client to dangle the legs while sitting in a chair
b. Teach the client about foods low in sodium
c. Determine medication adherence by the client
d. Notify the provider of the client’s weight gain
15. A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should
monitor for which of the following as an indication of an allergic reaction following the injection?
a. Urticaria
b. Bradycardia
c. Pallor
d. Dyspepsia
16. A nurse is teaching a client who has angina a new prescription for sublingual nitroglycerin
tablets. Which of the following instructions should the nurse include in the teaching?
a. “Discard any tablets you do not use every 6 months.”
b. “Take one tablet each morning 30 minutes prior to eating.”
c. “Keep the tablets at room temperature in their original glass bottle.”
d. “Place the tablet between your cheek and gum to dissolve.”
17. A nurse is providing teaching to a client who has a new prescription for theophylline, a
sustained-released capsule. Which of the following statements by the client indicates an
understanding of the teaching?
a. “I can take my medication in the morning with my coffee.”
b. “I may sprinkle the medication in applesauce.”
c. “I should limit my fluid intake while on this medication.”
d. “I will need to have blood levels drawn.”
18. A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to
client who has diabetes mellitus following actions should the nurse take first?
a. Withdraw the regular insulin from the viral
b. Withdraw the NPH insulin form the vial
c. Inject air into the NPH vial
d. Inject air into the regular insulin vial
19. A nurse is preparing to administer subcutaneous heparin to a client. Which of the following
should the nurse take?
a. Massage the site after administering the medication
b. Use a 21-gauge needle for the injection
c. Aspirate before injecting the medication
d. Insert the needle at least 5 cm (2 in) from the umbilicus
20. A nurse is caring for a client who has a prescription for amoxicillin. Which of the following
findings indicates the client is experiencing an allergic reaction?
a. Nausea
b. Cardiac dysrhythmia
c. Laryngeal edema
d. Insomnia
i. amoxicillin side effects include, renal impairment, hyperkalemia, dysrhythmias,
hypernatremia
allergic reaction: Urticaria, rash, hypotension, dyspnea, swelling of
face/lips/tongue
21. A nurse is teaching a newly licensed nurse about medication reconciliation. The nurse should
instruct the newly licensed nurse to perform medication reconciliation for which of the
following?
a. A client who has a referral for social services
b. A client who is transdermal to radiology
c. A client who is transferal to a step-down unit
d. A client who has a consultation for physical therapy
22. A nurse is reviewing the laboratory values of a client who is taking atorvastatin. Which of the
following laboratory values indicates the treatment has been effective?
a. BUN 15 mg/dL
b. Blood glucose 90 mg/dL
c. Urine specific gravity 1.020
d. LDL 120 mg/dL
23. A nurse is receiving a medication prescription by telephone from a provider. The provider states,
“Administer 6 milligrams of morphine IV push every 3 hours as needed for acute pain.” How
should the nurse transcribe the prescription in the client’s medical record?
a. Morphine 6 mg IV push every 3 hr PRN acute pain
b. MSO 6 mg IV push every 3 hr PRN acute pain
c. MS 6 mg IV push every 3 hr PRN acute pain
d. Morphine 6.0 mg IV push every 3 hr PRN acute pain
24. A nurse is assessing a client’s IV infusion site and notes that the site is cool and edematous.
Which of the following actions should the nurse take?
a. Show the IV solution rate
b. Initiate a new IV distal to the initial site
c. Maintain the extremity below the level of the heart
d. Apply a warm, moist compress
25. A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the
following statements should the nurse include in the teaching?
a. “Diarrhea is a common adverse effect of this medication.”
b. “Ringing in the ears is an expected adverse effect of this medication.”
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