Detailed Answer Key

RN 46 C9 Pharmacology

1. A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous
rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse
effects?

A. Constipation

Rationale: Rifampin does not cause constipation. More common gastrointestinal effects are diarrhea and
nausea.

B. Black colored stools

Rationale: It is most commonly iron supplements that cause stools to turn black, not rifampin.

C. Staining of teeth

Rationale: Teeth may be stained from taking liquid iron preparations, not from taking rifampin.

D. Body secretions turning a red-orange color

Rationale: Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine,
stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.

2. A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused
breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

A. Check the client's vital signs.

Rationale: It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the
nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should
withhold the medication and call the provider if the client's heart rate is less than 60 bpm.

B. Request a dietitian consult.

Rationale: While the dietitian might be able to assist the client with making appropriate food choices, this is
not the first action the nurse should take.

C. Suggest that the client rests before eating the meal.

Rationale: While this intervention might be appropriate, this is not the first action the nurse should take.

D. Request an order for an antiemetic.

Rationale: While this intervention might relieve the client's nausea, this is not the first action the nurse
should take.

3. A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO
once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following
responses should the nurse provide?

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A. "Crushing the medication might cause you to have a stomachache or indigestion."

Rationale: The pill is enteric-coated to prevent breakdown in the stomach and decrease the possibility of GI
distress. Crushing the pill destroys that protection.

B. "Crushing the medication is a good idea, and I can mix it in some ice cream for you."

Rationale: Crushing the pill will destroy the enteric coating, and the client should be advised against this.
The client should be told not to break, crush, or chew enteric-coated tablets.

C. "Crushing the medication would release all the medication at once, rather than over time."

Rationale: Crushing the pill will destroy the enteric coating, and the client should be advised against this,
but the enteric coating does not prevent the release of medication. Sustained release
preparations disburse the medication over time.

D. "Crushing is unsafe, as it destroys the ingredients in the medication."

Rationale: Many medications can safely be crushed to make them easier to swallow. The client should
check with his provider for information about which medications can be safely crushed.

4. A nurse is caring for four clients for whom she has to administer oral medications in the morning. The nurse should
administer which of the following medications before breakfast?

A. Alendronate

Rationale: The client must take alendronate first thing in the morning on an empty stomach and wait at
least 30 minutes before eating, drinking, or taking other medications.

B. Digoxin

Rationale: Digoxin treats hearts failure and dysrhythmias. While it is important that the client get the
morning dose in a timely manner, the nurse does not have to administer it before a meal.

C. Mycostatin mouthwash

Rationale: Any mouthwash or rinse is most effective after a meal.

D. Divalproex

Rationale: Divalproex, an anticonvulsant, helps control seizures and treats the manic phase of bipolar
disorder. The client should take the dose on time, but not necessarily before a meal.

5. A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering
the medication, the nurse should check to see that which of the following tests have been completed?

A. Thyroid hormone assay

Rationale: Thyroid testing is important because long-term use of lithium may lead to thyroid dysfunction.

B. Liver function tests

Rationale:

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LFTs must be monitored before and during valproic acid therapy, not lithium therapy.

C. Erythrocyte sedimentation rate

Rationale: This is not a necessary test related to lithium therapy.

D. Brain natriuretic peptide

Rationale: Brain natriuretic peptide (BNP) is not a necessary test related to lithium therapy. The BNP is
used to monitor heart failure.

6. A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The
client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses
should the nurse give?

A. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level."

Rationale: The effects of heparin begin within minutes. This response does not accurately answer the
client's question.

B. "A pharmacist is the person to answer that question."

Rationale: Contacting the pharmacist is not the appropriate answer for the nurse to give.

C. "Heparin does not dissolve clots. It stops new clots from forming."

Rationale: This statement accurately answers the client's question.

D. "The oral medication you will take after this IV will dissolve the clot."

Rationale: This is not a correct response. Warfarin, a PO medication that is often started after the client
has been on heparin, does not dissolve clots.

7. A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and
albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the
teaching?

A. "If my breathing begins to feel tight, I will use the cromolyn immediately."

Rationale: Cromolyn, a leukotriene modifier, is used for prophylaxis treatment of asthma, not acute attacks.
Albuterol, a short acting bronchodilator, should be used for the treatment of acute
bronchospasms.

B. "I will be sure to take the albuterol before taking the cromolyn."

Rationale: The client should always use the bronchodilator (albuterol) prior to using the leukotriene modifier
(cromolyn). Using the bronchodilator first allows the airways to be opened, ensuring that the
maximum dose of medication will get to the client's lungs.

C. "I will use both medications immediately after exercising."

Rationale:

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Both albuterol and cromolyn are used to prevent exercise-induced bronchospasm, but
administration should be made prior, not after, exercising.

D. "I will administer the medications 10 minutes apart."

Rationale: Inhalations of different medications should be administered 2 to 5 minutes apart.

8. A nurse is completing a medication history for a client who reports using over-the-counter calcium carbonate
antacid. Which of the following recommendations should the nurse make about taking this medication?

A. Decrease bulk in the diet to counteract the adverse effect of diarrhea.

Rationale: The major adverse effect of calcium carbonate is constipation. The nurse should recommend
the client increase bulk in the diet.

B. Take the medication with dairy products to increase absorption.

Rationale: Taking calcium carbonate with milk predisposes the client to milk alkali syndrome, which is
characterized by headache, confusion, nausea, vomiting, alkalosis, and hypercalcemia.

C. Reduce sodium intake.

Rationale: Clients who take aluminum hydroxide, not calcium carbonate, antacids should be advised
against excessive sodium intake in the diet.

D. Drink a glass of water after taking the medication.

Rationale: Calcium carbonate is a dietary supplement used when the amount of calcium taken in the diet is
not enough. Calcium carbonate may also be used as an antacid to relieve heartburn, acid
indigestion, and stomach upset. The client should drink a full glass of water after taking an
antacid to enhance its effectiveness.

9. A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5
days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both
anticoagulants are necessary. Which of the following statements should the nurse make?

A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic
level."

Rationale: Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and
help prevent thrombosis formation in the blood vessels. However, these medications work in
different ways to achieve therapeutic coagulation and must be given together until therapeutic
levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days.
When the client's PT and INR are within therapeutic range, the heparin can be discontinued.

B. "I will call the provider to get a prescription for discontinuing the IV heparin today."

Rationale: Discontinuing the IV heparin is not indicated at this time.

C. "Both heparin and warfarin work together to dissolve the clots."

Rationale:

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Neither medication dissolves clots that have already formed.

D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."

Rationale: Neither medication increases the effects of the other.

10. A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone.
Which of the following instructions should the nurse provide?

A. Check the pulse after medication administration.

Rationale: Beclomethasone, an inhaled glucocorticoid, does not cause cardiac side effects.

B. Take the medication with meals.

Rationale: Oral, not inhaled, glucocorticoids should be administered with food.

C. Rinse the mouth after administration.

Rationale: Use of glucocorticoids by metered dose inhaler can allow a fungal overgrowth in the mouth.
Rinsing the mouth after administration can lessen the likelihood of this complication.

D. Limit caffeine intake.

Rationale: Caffeine does not interact with beclomethasone and is not contraindicated.

11. A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The
nurse should inform the client that this medication is contraindicated in clients who have a history of which of the
following conditions?

A. Asthma

Rationale: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can
cause bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth
muscle relaxation.

B. Glaucoma

Rationale: Beta-blockers are contraindicated in clients who have cardiogenic shock, but are not
contraindicated in a client who has glaucoma.

C. Depression

Rationale: Beta-blockers are contraindicated in clients who have AV heart block, but are not
contraindicated in clients who have depression.

D. Migraines

Rationale: Beta-blockers are used for prophylactic treatment of migraine headaches.

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12. A nurse is teaching a client who has a new prescription for colchicine to treat gout. Which of the following
instructions should the nurse include?

A. "Take this medication with food if nausea develops."

Rationale: The client should report manifestations of gastric toxicity such as nausea, vomiting, and
diarrhea. The medication is discontinued for these effects.

B. "Monitor for muscle pain."

Rationale: This medication can cause rhabdomyolysis. The client should monitor and report muscle pain.

C. "Expect to have increased bruising."

Rationale: The client should report manifestations of thrombocytopenia such as bruising and bleeding,
which are adverse effects of this medication.

D. "Increase your intake of grapefruit juice."

Rationale: Grapefruit juice can interfere with the metabolism of this medication and increase the risk for
toxicity.

13. A nurse is teaching a client who has chronic kidney disease and a new prescription for epoetin alfa. The nurse
should instruct the client to increase dietary intake of which of the following substances?

A. Iron

Rationale: Epoetin alfa is a synthetic form of erythropoietin, a substance produced by the kidneys that
stimulates the bone marrow to produce red blood cells. Increased iron is needed for the
production of hemoglobin and red blood cells by the bone marrow.

B. Protein

Rationale: The client who has chronic kidney disease is at risk for uremia and should eat a low-protein
diet.

C. Potassium

Rationale: The client who has chronic kidney disease is at risk for hyperkalemia and should eat a
low-potassium diet.

D. Sodium

Rationale: The client who has chronic kidney disease is at risk for hypernatremia and should eat a
low-sodium diet.

14. A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client
reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following
scenarios should the nurse document as the explanation for this situation?

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A. The client not been taking the medication properly.

Rationale: The nurse should not document the client has not been taking the medication properly without
further investigation. The client is able to tell the nurse that he had to increase the dose, which
does not indicate taking the medication improperly.

B. The client is experiencing episodes of confusion.

Rationale: The nurse should not document the client is experiencing confusion. The client is clearly able to
tell the nurse that that he had to increase the dose to achieve pain relief. This does not indicate
the client is confused.

C. The client has become addicted to the medication.

Rationale: Addiction is the compulsive need for and use of a habit-forming substance, such as a narcotic.
However, this client is not describing addiction, and addiction is not a concern when treating a
terminal client who has cancer pain.

D. The client developed a tolerance to the medication.

Rationale: The nurse should document that the client has developed a tolerance to the medication.
Morphine is a narcotic analgesic used for the treatment of severe pain. Tolerance is an
adverse effect of narcotic analgesics in which a larger dose is needed to produce the same
response.

15. A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and
tachycardia. Which of the following actions should the nurse take?

A. Document that the client experienced an anaphylactic reaction to the medication.

Rationale: The nurse should document that this client is experiencing Red man syndrome, which can lead
to anaphylaxis if not resolved.

B. Change the IV infusion site.

Rationale: This client is experiencing Red man syndrome. Changing the IV site will not alter this
phenomenon, which is due to a reaction to the medication.

C. Decrease the infusion rate on the IV.

Rationale: This client is experiencing Red man syndrome, which includes a flushing of the neck, face,
upper body, arms and back along with tachycardia, hypotension and urticaria. This can lead to
an anaphylactic reaction if the IV infusion rate is not slowed down to run greater than 1 hour.

D. Apply cold compresses to the neck area.

Rationale: This client is experiencing Red man syndrome. Applying a cold compress to the flushed area of
the neck will not resolve this phenomenon, which can lead to anaphylaxis if not addressed.

16. A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the
following instructions should the nurse give to the client?

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A. "If the medicine causes an upset stomach, take an antacid at the same time."

Rationale: Ciprofloxacin is best absorbed on an empty stomach with a full glass of water. Antacids
containing either magnesium or aluminum can decrease the absorption of ciprofloxacin. If an
antacid is taken, the nurse should instruct the client to wait at least 2 hr after administering the
ciprofloxacin.

B. "Limit your daily fluid intake while taking this medication."

Rationale: The nurse should instruct the client that ciprofloxacin is a fluoroquinolone antibiotic used in the
treatment of mild to severe infections. It is excreted primarily via the kidneys, and drinking extra
fluids will reduce the risk of crystallization in the kidneys.

C. "This medication can cause photophobia, so be sure to wear sunglasses outdoors."

Rationale: Ciprofloxacin can cause phototoxicity, putting the client at risk for extreme sunburn from
minimal sun exposure. The client should wear protective clothing when out in the sun.
Photophobia is eye sensitivity to light.

D. "You should report any tendon discomfort you experience while taking this medication."

Rationale: The nurse should instruct the client to report any tendon discomfort as well as swelling or
inflammation of the tendons due to the risk of tendon rupture.

17. A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat
chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor?

A. Headache

Rationale: Headache is a common adverse effect of ondansetron. Analgesic relief is often required.

B. Dependent edema

Rationale: Dependent edema is not an adverse effect of ondansetron.

C. Polyuria

Rationale: Urinary retention, not polyuria, is a common adverse effect of ondansetron.

D. Photosensitivity

Rationale: Photosensitivity is not an adverse effect of ondansetron.

18. A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which
of the following adverse effects should the nurse monitor when giving this medication?

A. Hyperthermia

Rationale: Temperature is not affected by verapamil.

B. Hypotension

Rationale:

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Verapamil, a calcium channel blocker, can be used to control supraventricular

tachyarrhythmias. It also decreases blood pressure and acts as a coronary vasodilator and
antianginal agent. A major adverse effect of verapamil is hypotension; therefore, blood
pressure and pulse must be monitored before and during parenteral administration.

C. Ototoxicity

Rationale: Verapamil is not toxic to the ear.

D. Muscle pain

Rationale: Verapamil does not cause muscle pain.

19. A nurse is caring for a client who has a fungal infection and has a new prescription for amphotericin B. Which of
the following laboratory values should the nurse report to the provider before initiating the medication?

A. Sodium 140 mEq/L

Rationale: The sodium level is within the recommended reference range. It is not necessary to notify the
provider before initiating the medication for this laboratory finding.

B. Potassium 4.5 mEq/L

Rationale: The potassium level is within the recommended reference range. It is not necessary to notify
the provider before initiating the medication for this laboratory finding.

C. BUN 55 mg/dL

Rationale: This BUN level is above the expected reference range (10-20 mg/dL). Amphotericin B is
nephrotoxic and is contraindicated if BUN is > 40mg/dL. The nurse should report this laboratory
value to the provider before initiating the medication.

D. Glucose 120 mg/dL

Rationale: The glucose level is within the recommended reference range. It is not necessary to notify the
provider before initiating the medication for this laboratory finding.

20. A nurse is providing teaching to a client who has renal failure and an elevated phosphorous level. The provider
instructed the client to take aluminum hydroxide 300 mg PO three times daily. For which of the following adverse
effects should the nurse inform the client?

A. Constipation

Rationale: Constipation is a common side effect of aluminum-based antacids. The nurse should instruct
the client to increase fiber intake and that stool softeners or laxatives may be needed.

B. Metallic taste

Rationale: Clients report that antacids have a chalky, rather than metallic, taste.

C. Headache

Rationale:

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Headache is not an adverse effect of aluminum hydroxide.

D. Muscle spasms

Rationale: Muscle spasms are not an adverse effect of aluminum hydroxide.

21. A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following
findings is a manifestation of levothyroxine overdose?

A. Insomnia

Rationale: Levothyroxine overdose will result in manifestations of hyperthyroidism, which include

insomnia, tachycardia, and hyperthermia.

B. Constipation

Rationale: Constipation is a manifestation of hypothyroidism and indicates an inadequate dose of

levothyroxine.

C. Drowsiness

Rationale: Drowsiness is a manifestation of hypothyroidism and indicates an inadequate dose of

levothyroxine.

D. Hypoactive deep-tendon reflexes

Rationale: Hypoactive deep-tendon reflexes are manifestations of hypothyroidism and indicate an

inadequate dose of levothyroxine.

22. A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to
discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of
the following adverse effects?

A. Hyperglycemia

Rationale: Hyperglycemia is an adverse effect of prednisone, especially for clients who have a history of
diabetes mellitus. Once the medication is discontinued, however, this adverse effect should not
occur.

B. Adrenocortical insufficiency

Rationale: Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the
adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe
allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress
production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of
adrenal insufficiency.

C. Severe dehydration

Rationale: Fluid retention is an adverse effect of prednisone. Once the medication is discontinued,
however, this adverse effect should not occur.

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D. Rebound pulmonary congestion

Rationale: Fluid retention is an adverse effect of prednisone. Rebound pulmonary congestion should not
occur with withdrawal of prednisone. Prednisone has no direct effect on the client's pulmonary
congestion.

23. A nurse is preparing a client for surgery. Prior to administering the prescribed hydroxyzine, the nurse should
explain to the client that the medication is for which of the following indications? (Select all that apply.)

A. Controlling emesis

B. Diminishing anxiety

C. Reducing the amount of narcotics needed for pain relief

D. Preventing thrombus formation

F. Drying secretions

Rationale: Controlling emesis is correct. Hydroxyzine is an effective antiemetic that may be used to control
nausea and vomiting in preoperative and postoperative clients.Diminishing anxiety is correct.
Hydroxyzine is an effective antianxiety agent that may be used to diminish anxiety in surgical
clients, as well as in clients who have moderate anxiety.Reducing the amount of narcotics
needed for pain relief is correct. Hydroxyzine potentiates the actions of narcotic pain
medications; therefore, narcotic requirements may be significantly reduced.Preventing
thrombus formation is incorrect. Hydroxyzine, an antihistamine, has no role in the prevention of
thrombi.Drying secretions is correct. Hydroxyzine, an antihistamine, commonly causes drying
of the oral mucous membranes.

24. A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV
bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy
and short of breath. Which of the following actions should the nurse take first?

A. Stop the infusion.

Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place
the priority on stopping the infusion. The client is exhibiting signs of penicillin anaphylaxis and
the first action that should be taken is to withdraw the medication.

B. Call the client's provider.

Rationale: The nurse should call the client's provider; however, another action is the priority.

C. Elevate the head of the bed.

Rationale: The nurse should elevate the head of the bed; however, another action is the priority.

D. Auscultate the client's breath sounds.

Rationale: The nurse should auscultate the client's breath sounds; however, another action is the priority.

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25. A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical
ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for
which of the following purposes?

A. Decrease chest wall compliance

Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis by relaxing skeletal
muscles, which improves chest wall compliance.

B. Suppress respiratory effort

Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the
client's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over
the work of breathing for the client. This therapy is especially helpful for a client who has ARDS
and poor lung compliance.

C. Induce sedation

Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and have no sedative
effect at all. A sedative or analgesic should be prescribed as an adjunct to the pancuronium.

D. Decrease respiratory secretions

Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis. An adverse effect of
this medication is increased production of respiratory secretions.

26. A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect
of the medication?

A. Decreased blood pressure

Rationale: Lisinopril, an ACE inhibitor, may be used alone or in combination with other antihypertensives
in the management of hypertension and congestive heart failure. A therapeutic effect of the
medication is a decrease in blood pressure.

B. Increase of HDL cholesterol

Rationale: This is not an intended effect of lisinopril.

C. Prevention of bipolar manic episodes

Rationale: This is not an intended effect of lisinopril.

D. Improved sexual function

Rationale: This is not an intended effect of lisinopril. Lisinopril may in fact cause sexual dysfunction and
impotence.

27. A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following

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instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine?

A. "Administer the medication with food."

Rationale: Administering diphenhydramine with food might minimize gastrointestinal effects, but will not
relieve dry mouth.

B. "Chew on sugarless gum or suck on hard, sour candies."

Rationale: Clients who report dry mouth can get the most effective relief by sucking on hard candies
(especially the sour varieties that stimulate salivation), chewing gum, or rinsing the mouth
frequently. It is the local effect of these actions that provides comfort to the client.

C. "Place a humidifier at your bedside every evening."

Rationale: This action might help to ease the work of breathing when the client has congestion, but it will
not relieve the manifestation of dry mouth.

D. "Discontinue the medication and notify your provider."

Rationale: It is not necessary for the client to discontinue the use of diphenhydramine for dry mouth. The
nurse should inform the client to notify the provider of any confusion, sedation, or hypotension.

28. A nurse is caring for a client who has an infection and a prescription for gentamicin intermittent IV bolus every 8 hr.
A peak and trough is required with the next dose. Which of the following actions should the nurse take to obtain
an accurate gentamicin serum level?

A. Draw a trough level at 0900 and a peak level at 2100.

Rationale: This is not the correct schedule for obtaining peak and trough serum levels.

B. Draw a peak level 90 min prior to administering the medication and a trough level 90 min after the dose.

Rationale: This is not the correct schedule for obtaining peak and trough serum levels.

C. Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose.

Rationale: Timing of the peak and trough is based on the pharmacokinetics of absorption and the half-life
of the medication. The trough level is the lowest serum level after pharmacokinetic effects have
taken place. For divided doses, correct timing for the trough is just before administering the
next dose. The peak is the highest serum level of the medication; if this level is too low, then
the medication will not be effective. Correct timing for the peak is between 30 and 60 min after
the dose has finished infusing.

D. Draw a peak level at 0900 and a trough level at 2100.

Rationale: This is not the correct schedule for obtaining peak and trough serum levels.

29. A nurse in a substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports
having discontinued the medication after experiencing severe nausea and vomiting. Which of the following
reasons should the nurse suspect to be a likely cause of the client's distress?

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A. The client demonstrated an allergic response to the medication.

Rationale: An allergic response to disulfiram presents as dermatitis.

B. The client experienced a common side effect to the medication.

Rationale: Common side effects of disulfiram are drowsiness, headache, and a metallic aftertaste.

C. The client consumed alcohol while taking the medication.

Rationale: Disulfiram is given to clients who have a history of alcohol abuse. It produces a sensitivity to
alcohol that results in a highly unpleasant reaction when the client ingests even small amounts
of alcohol. When combined with alcohol, disulfiram produces nausea and vomiting.

D. The client took an overdose of the medication.

Rationale: An overdose might result in a severe reaction such as respiratory depression, cardiovascular
collapse, arrhythmias, myocardial infarction, acute congestive heart failure, unconsciousness,
convulsions, or death.

30. A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of
the following findings indicates a therapeutic response to the medication?

A. Decrease in level of thyroxine (T4)

Rationale: If the dose of this medication has been adequate, the nurse should see an increase in the T4.

B. Increase in weight

Rationale: If the dose of this medication has been adequate, the nurse should see a decrease in weight,
as hypothyroidism causes a decrease in metabolism with weight gain.

C. Increase in hr of sleep per night

Rationale: If the dose of this medication has been adequate, the nurse should see a decrease in the hr of
sleep per night, as hypothyroidism causes sluggishness with increased hr of sleep.

D. Decrease in level of thyroid stimulating hormone (TSH).

Rationale: In hypothyroidism, the nonfunctioning thyroid gland is unable to respond to the TSH, and no
endogenous thyroid hormones are released. This results in an elevation of the TSH level as the
anterior pituitary continues to release the TSH to stimulate the thyroid gland. Administration of
exogenous thyroid hormones, such as levothyroxine, turns off this feedback loop, which results
in a decreased level of TSH.

31. A nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. Prior to
beginning the infusion, the nurse verifies the client's current cumulative lifetime dose of the medication. For which
of the following reasons is this verification necessary?

A. An excess amount of doxorubicin can lead to myelosuppression.

Rationale:

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Myelosuppression is a common and life-threatening adverse reaction to doxorubicin that leads

to leukopenia and thrombocytopenia. If platelet and WBC counts become too low, it might be
necessary to hold or reduce doses of doxorubicin. However, myelosuppression is reversible
and is not the reason for a lifetime cumulative dose limit.

B. Exceeding the lifetime cumulative dose limit of doxorubicin might cause extravasation.

Rationale: Precautions should be taken to avoid extravasation of doxorubicin, as the medication is

extremely irritating to tissues. However, extravasation is not the reason for a lifetime cumulative
dose limit.

C. An excess amount of doxorubicin can lead to cardiomyopathy.

Rationale: Doxorubicin is an antineoplastic antibiotic used in the treatment of various cancers. Irreversible
cardiomyopathy with congestive heart failure can result from repeated doses of doxorubicin,
and prolonged use can also cause severe heart damage, even years after the client has
stopped taking it. The maximum cumulative dose a client should receive is 550 mg/m2 or 450
mg/m2 with a history of radiation to the mediastinum.

D. Exceeding the lifetime cumulative dose limit of doxorubicin might produce red tinged urine and sweat.

Rationale: Red tinged urine and sweat is an adverse effect of doxorubicin that the client should be
informed of. However, this is not a life threatening effect and is not the reason for a lifetime
cumulative dose limit.

32. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new
prescription for timolol eye drops. Which of the following instructions should the nurse provide?

A. The medication is to be applied when the client is experiencing eye pain.

Rationale: The client needs to take the medications daily to reduce intraocular pressure and preserve
remaining eyesight.

B. The medication will be used until the client's intraocular pressure returns to normal.

Rationale: Treatment for open-angle glaucoma is to continue for life. Abrupt discontinuation can worsen
the client's condition.

C. The medication should be applied on a regular schedule for the rest of the client's life.

Rationale: Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, or
decrease its production, or both. The client must continue the eye drops on an uninterrupted
basis for life to maintain intraocular pressure at an acceptable level.

D. The medication is to be used for approximately 10 days, followed by a gradual tapering off.

Rationale: Treatment for open-angle glaucoma is to continue for life.

33. A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications,
including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?

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A. Relief of heartburn

Rationale: Histamine2 receptor antagonists are used to treat duodenal ulcers and prevent their return. In
over-the-counter strengths, these medications, such as cimetidine and ranitidine, are used to
relieve or prevent heartburn, acid indigestion, and sour stomach.

B. Cessation of diarrhea

Rationale: This is not a therapeutic effect of taking H2RA.

C. Passage of flatus

Rationale: This is not a therapeutic effect of taking H2RA.

D. Absence of constipation

Rationale: This is not a therapeutic effect of taking H2RA.

34. A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of
the following instructions should the nurse provide?

A. Consume a high-protein diet.

Rationale: The nurse should instruct the client that a high-protein diet should be avoided, as it decreases
theophylline's duration of action.

B. Administer the medication with food.

Rationale: The nurse should instruct the client that theophylline should be administered with 8 oz of water
if GI upset occurs. It should not be administered with food.

C. Avoid caffeine while taking this medication.

Rationale: The nurse should instruct the client that caffeine should be avoided while taking theophylline,
as it can increase central nervous system stimulation.

D. Increase fluids to 1L/per day.

Rationale: The nurse should instruct the client to increase fluid intake to 2L/day while taking theophylline
to decrease the thickness of mucous secretions related to emphysema.

35. A nurse is caring for a client who is taking naproxen following an exacerbation of rheumatoid arthritis. Which of the
following statements by the client requires further discussion by the nurse?

A. "I signed up for a swimming class."

Rationale: Daily exercise can relieve soreness caused by stiff, unused muscles and helps to maintain joint
range of motion.

B. "I've been taking an antacid to help with indigestion."

Rationale:

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NSAIDs, like naproxen, can cause serious adverse gastrointestinal reactions such as
ulceration, bleeding, and perforation. Warning manifestations such as nausea or vomiting,
gastrointestinal burning, and blood in the stool reported by the client require further
investigation by the nurse. The client might be taking an antacid because he is experiencing
one or more of these manifestations.

C. "I've lost 2 pounds since my appointment 2 weeks ago."

Rationale: This rate of weight loss is acceptable and indicates that the client is aware that decreased
weight will decrease joint stress.

D. "The naproxen is easier to take when I crush it and put it in applesauce."

Rationale: Naproxen can be crushed or swallowed whole.

36. A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin.
Which of the following statements by the client indicates a need for further teaching?

A. "I will notify my doctor before taking any other medications."

Rationale: Many medication interactions can occur with phenytoin; therefore, the client's provider should
be notified that the client is taking phenytoin.

B. "I have made an appointment to see my dentist next week."

Rationale: The client understands that phenytoin causes an overgrowth of the gums that makes dental
monitoring important.

C. "I know that I cannot switch brands of this medication."

Rationale: The client understands that bioavailability varies with different brands, so no substitutions
should be made.

D. "I'll be glad when I can stop taking this medicine."

Rationale: Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on

anticonvulsant medications commonly require them for lifetime administration, and phenytoin
should not be stopped without the advice of the client's provider.

37. A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions
by the client indicates an understanding of the teaching?

A. The client holds his breath for 10 seconds after inhaling the medication.

Rationale: The medication should be retained in the lungs for a minimum of 10 seconds so the maximum
amount of the dosage can be delivered properly to the airways. To use the inhaler, the client
exhales normally just prior to releasing the medication, inhales deeply as the medication is
released, then holds the medication in the lungs for approximately 10 seconds prior to exhaling.

B. The client takes a quick inhalation while releasing the medication from the inhaler.

Rationale:

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The client should take a slow and deep inhalation for 3 to 5 seconds while administering the
medication.

C. The client exhales as the medication is released from the inhaler.

Rationale: Exhaling as the medication is released from the inhaler means that no medication will reach the
client's bronchioles. The client should inhale slowly as the medication is released from the
inhaler.

D. The client waits 10 min between inhalations.

Rationale: The client should wait approximately 20 to 30 seconds between inhalations of the same
medication, and 2 to 5 minutes between inhalations of different medications for maximum
benefit.

38. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following
statements by the client indicates an adverse effect of the medication?

A. "I can walk a mile a day."

Rationale: Improving the client's cardiac output, which in turn will improve the client's exercise tolerance,
is a therapeutic response to digoxin.

B. "I've had a backache for several days."

Rationale: Backaches are not an adverse effect of digoxin.

C. "I am urinating more frequently."

Rationale: Improving the client's cardiac output, which in turn will increase blood flow to the kidneys and
urination, is a therapeutic response to digoxin.

D. "I feel nauseated and have no appetite."

Rationale: Anorexia, nausea, vomiting, and abdominal discomfort are early signs of digoxin toxicity.

39. A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency
anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals.
Which of the following responses should the nurse make?

A. "Taking the medication between meals will help you avoid becoming constipated."

Rationale: Taking the medication with food can reduce the GI symptoms associated with it. However,
taking the medication between meals maximizes absorption.

B. "Taking the medication with food increases the risk of esophagitis."

Rationale: Reclining immediately after taking ferrous sulfate may lead to esophageal corrosion. Clients
should remain upright for 15-30 min following administering.

C. "Taking the medication between meals will help you absorb the medication more efficiently."

Rationale:

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Ferrous sulfate provides the iron needed by the body to produce red blood cells. Taking iron
supplements between meals helps to increase the bioavailability of the iron.

D. "The medication can cause nausea if taken with food."

Rationale: Taking ferrous sulfate with food can reduce the GI symptoms associated with it. However,
taking the medication between meals maximizes absorption.

40. A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need
this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is
used to decrease levels of which of the following components in the bloodstream?

A. Glucose

Rationale: Lactulose does not decrease serum glucose.

B. Ammonia

Rationale: Lactulose, a disaccharide, is a sugar that works as an osmotic diuretic. It prevents absorption
of ammonia in the colon. Accumulation of ammonia in the bloodstream, which occurs in
pathologic conditions of the liver, such as cirrhosis, may affect the central nervous system,
causing hepatic encephalopathy or coma.

C. Potassium

Rationale: Lactulose has no effect on the potassium level.

D. Bicarbonate

Rationale: Lactulose has no effect on the bicarbonate level.

41. A nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral
therapy. The nurse should monitor the client for which of the following adverse effects of this medication?

A. Cardiac dysrhythmia

Rationale: Zidovudine has no documented adverse effects on the heart.

B. Metabolic alkalosis

Rationale: Lactic acidosis, not metabolic alkalosis, is an adverse effect of zidovudine.

C. Renal failure

Rationale: Zidovudine is not known as a nephrotoxic agent.

D. Aplastic anemia

Rationale: Severe myelosuppression that results in anemia (decreased red blood cells), agranulocytosis
(decreased white blood cells), and thrombocytopenia (decreased platelets) is a life-threatening
adverse reaction to zidovudine therapy. Consequently, zidovudine must be used cautiously in

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clients already experiencing myelosuppression, and the client must be monitored with a CBC
performed every few weeks for early detection of marrow failure, which may lead to aplastic
anemia.

42. A nurse is providing teaching to a client who has oral candidiasis and a new prescription for nystatin suspension.
Which of the following statements by the client indicates an understanding of the teaching?

A. "I will store the medication at room temperature."

Rationale: Nystatin oral suspension should be stored at room temperature.

B. "I will take the medicine every morning on an empty stomach."

Rationale: The action of nystatin is local, and it is not absorbed through intact skin or mucous membranes.
There is no reason to take the medication on an empty stomach.

C. "I will spit the medication out after swishing it around my mouth."

Rationale: Nystatin must be swallowed to maximize the medication's local effects on the mucosal lining of
the upper gastrointestinal tract.

D. "I will only need to take this medication for a few days."

Rationale: Long-term therapy may be needed to clear candidiasis. The client should be instructed to
complete the entire dose of medication.

43. A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of
the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?

A. The leukocyte count

Rationale: Epoetin alfa does not affect the leukocyte, or WBC, count.

B. The platelet count

Rationale: An increase in platelets is not the therapeutic or desired effect of epoetin alfa.

C. The hematocrit (Hct)

Rationale: Epoetin alfa is an antianemic medication that is indicated in the treatment of clients who have
anemia due to reduced production of endogenous erythropoietin, which may occur in clients
who have end-stage renal disease or myelosuppression from chemotherapy. The therapeutic
effect of epoetin alfa is enhanced red blood cell production, which is reflected in an increased
RBC, Hgb, and Hct.

D. The erythrocyte sedimentation rate (ESR)

Rationale: Epoetin alfa does not affect the ESR, which is a measurement of inflammation.

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44. A nurse is providing teaching for a client who is newly diagnosed with type 2 diabetes mellitus and has a
prescription for glipizide. Which of the following statements by the nurse best describes the action of glipizide?

A. "Glipizide absorbs the excess carbohydrates in your system."

Rationale: Glipizide is an oral antidiabetic medication in the pharmacological classification of sulfonylurea

agents. This is not the mechanism of action.

B. "Glipizide stimulates your pancreas to release insulin."

Rationale: Glipizide is an oral antidiabetic medication in the pharmacological classification of sulfonylurea

agents. These medications help to lower blood glucose levels in clients who have type 2
diabetes mellitus using several methods, including reducing glucose output by the liver,
increasing peripheral sensitivity to insulin, and stimulating the release of insulin from the
functioning beta cells of the pancreas.

C. "Glipizide replaces insulin that is not being produced by your pancreas."

Rationale: This explanation is closer to the mechanism of action of exogenous insulin, which is insulin that
the client takes subcutaneously. Glipizide is an oral antidiabetic medication in the
pharmacological classification of sulfonylurea agents.

D. "Glipizide prevents your liver from destroying your insulin."

Rationale: Glipizide is an oral antidiabetic medication in the pharmacological classification of sulfonylurea

agents. Sulfonylurea agents reduce the glucose output of the liver.

45. A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following
laboratory values should the nurse monitor for a therapeutic effect of warfarin?

A. Hemoglobin (Hgb)

Rationale: Warfarin does not affect the hemoglobin level.

B. Prothrombin time (PT)

Rationale: This test is used to monitor warfarin therapy. For a client receiving full anticoagulant therapy,
the PT should typically be approximately two to three times the normal value, depending on the
indication for therapeutic anticoagulation.

C. Bleeding time

Rationale: This test is not used to monitor therapeutic anticoagulation. Abnormal bleeding time results are
usually associated with platelet dysfunction.

D. Activated partial thromboplastin time (aPTT)

Rationale: This test is used to monitor heparin, not warfarin, therapy.

46. A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After
extubation from the ventilator, in which of the following positions should the client be placed?

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A. Prone

Rationale: Placing the client who is postoperative following a right pneumonectomy on his stomach is not
the appropriate position following extubation from the ventilator.

B. On the nonoperative side

Rationale: Placing the client who is postoperative following a right pneumonectomy on his left side is not
the appropriate position following extubation from the ventilator.

C. Sims'

Rationale: Placing the client who is postoperative following a right pneumonectomy in Sims' position is not
appropriate following extubation from the ventilator.

D. Semi-Fowler's

Rationale: Pneumonectomy is the surgical removal of the lung, which is most commonly performed to
remove a tumor in a client who has lung cancer. Following extubation from the ventilator, the
client should be placed in semi-Fowler's position to help to ensure adequate ventilation and
decrease the risk of complications. This position also offers the client the most comfort.

47. A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine
prescribed for one client was inadvertently administered to another client. Which of the following actions should the
nurse take first?

A. Notify the client's provider.

Rationale: The nurse should notify the client's provider to inform her of the event; however, there is
another action the nurse should take first.

B. Check the client's vital signs.

Rationale: The first action the nurse should take using the nursing process is to assess the client. The
nurse should know that the action of nifedipine is to lower blood pressure. Immediately upon
realizing the error, the nurse should check the client's vital signs (especially the client's blood
pressure) to ensure that the client is not hypotensive as a result. Only after ensuring that the
client is safe and has stable vital signs should the nurse take other actions.

C. Fill out an occurrence form.

Rationale: The nurse should fill out an occurrence form to report the event to hospital personnel; however,
there is another action the nurse should take first.

D. Administer the medication to the correct client.

Rationale: The nurse should administer the medication to the correct client to fulfill the provider's
prescription; however, there is another action the nurse should take first.

48. A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is
receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse

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should explain that it has which of the following actions?

A. Prevents dysrhythmias

Rationale: Lidocaine is an antidysrhythmic medication that delays the conduction in the heart and reduces
the automaticity of heart tissue.

B. Slows intestinal motility

Rationale: Lidocaine does not have anticholinergic properties, as do some other antidysrhythmics such as
procainamide and quinidine. Also, clients who have cardiac problems should prevent
constipation. An anticholinergic medication would increase the risk for constipation.

C. Dissolves blood clots

Rationale: A fibrinolytic medication, such as alteplase, dissolves blood clots via the conversion of
plasminogen to plasmin.

D. Relieves pain

Rationale: Topical lidocaine is a local anesthetic that produces numbness or loss of feeling before surgery
or another painful procedure, but this is not the reason for administering it to this client.

49. A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which
of the following instructions should the nurse provide?

A. Take the medication on an empty stomach to decrease gastrointestinal irritation.

Rationale: Taking iron on an empty stomach may increase gastrointestinal side effects.

B. Take the medication with orange juice to enhance absorption.

Rationale: Ascorbic acid (vitamin C), which is found in orange juice, will enhance the absorption of iron
and increase its bioavailability. This will also help to decrease the gastrointestinal side effects
of iron.

C. Take the medication with milk.

Rationale: Iron should not be taken with milk or antacids, because it decreases the absorption.

D. Rinse the mouth before taking the iron.

Rationale: The client should rinse the mouth after taking the ferrous sulfate liquid to prevent the
medication from staining the teeth.

50. A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following
instructions should the nurse provide the client's parent on administering the medication?

A. Give the medication in the morning daily.

Rationale: Montelukast is a leukotriene receptor antagonist that is used to prevent asthma symptoms. It

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works by blocking the action of leukotrienes (substances that cause inflammation, fluid
retention, mucous secretion, and constriction) in the client's lungs. Due to the side effect of
drowsiness, it is usually taken once a day in the evening.

B. Administer the medication 2 hr before exercise.

Rationale: Montelukast should be given daily during the evening, except when being used for
exercise-induced bronchospasm. It should then be given 2 hr before exercise, and not given
again for 24 hr.

C. Give the medication at the onset of wheezing.

Rationale: Montelukast is ineffective as a rescue medication.

D. Administer the granules mixed with 20 oz of water.

Rationale: Montelukast granules should be taken directly or mixed with certain soft foods (applesauce,
carrots, rice or ice cream).

51. A nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which
of the following actions should the nurse take when the client reports bleeding gums?

A. Explain to the client that this is an expected adverse effect.

Rationale: This is not an expected adverse effect of this medication.

B. Check the value of the client's current platelet count.

Rationale: The nurse should recognize that the bleeding is likely due to the adverse effect of the
chemotherapy and needs to be evaluated further. Bleeding gums is a sign of thrombocytopenia
(decreased platelet count) secondary to bone marrow suppression, which can be
life-threatening in a client who is receiving chemotherapy.

C. Instruct the client to use an electric toothbrush.

Rationale: The nurse should instruct the client to use a soft toothbrush if stomatitis is present.

D. Have the client make an appointment to see the dentist.

Rationale: The nurse should instruct the client to practice good oral care. Having the client see a dentist is
not the action the nurse should take to address the current problem.

52. A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations
of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

A. "I will report any loss of appetite."

Rationale: Anorexia is a common side effect, especially in the period after lithium has first been prescribed
and the body is adjusting to the medication. It is not a sign of toxicity.

B. "Increased flatulence is an indication of toxicity."

Rationale:

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Increased flatulence is a common adverse effect, especially in the period after lithium is first
prescribed and the body is adjusting to the medication. It is not a sign of toxicity.

C. "Vomiting is an indication of toxicity."

Rationale: Since vomiting and diarrhea are early signs of lithium toxicity, the client should omit the next
dose of lithium and call the provider.

D. "I will call my provider if I experience any headaches."

Rationale: Headaches are a common adverse effect, especially in the period after lithium has first been
prescribed and the body is adjusting to the medication. It is not a sign of toxicity.

53. A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication
safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?

A. Carbonated beverage

Rationale: While there are some medications that can interact with carbonated beverages, many
recommend the client take the dose with a carbonated beverage. Therefore, the nurse should
not include an across-the-board warning about carbonated beverages. Rather, the nurse
should instruct the clients to check the recommendation for each medication that they take.

B. Milk

Rationale: While there are some medications that can interact with milk, many recommend the client take
the dose with milk. Therefore, the nurse should not include an across-the-board warning about
milk. Rather, the nurse should instruct the clients to check the recommendation for each
medication that they take.

C. Orange juice

Rationale: While there are some medications that can interact with orange juice, many recommend the
client take the dose with juice. Therefore, the nurse should not include an across-the-board
warning about orange juice. Rather, the nurse should instruct the clients to check the
recommendation for each medication that they take.

D. Grapefruit juice

Rationale: There is a high rate of food-drug interactions between grapefruit juice and many medications
frequently taken by older adults, especially lipid-lowering agents. It is thought that one or more
of the chemicals (most likely flavonoids) in grapefruit juice alter the activity of specific enzymes
(such as CYP3A4 and CYP1A2) in the intestinal tract. These enzymes decrease the rate at
which medications enter the systemic circulation. This could allow a larger amount of these
drugs to reach the bloodstream, resulting in increased drug levels and possibly toxicity.

54. A nurse is caring for a client who has a bacterial infection and is receiving gentamicin. Which of the following
actions should the nurse take to minimize the risk of an adverse effect of the medication?

A. Limit the client's fluid intake.

Rationale:

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The client's fluid intake should not be limited while on gentamicin, as dehydration and renal
damage are adverse effects. Fluid intake should be at least 2 to 3 L daily unless
contraindicated.

B. Instruct the client to report agitation.

Rationale: Agitation is not an adverse effect of gentamicin.

C. Monitor the serum medication levels.

Rationale: A disadvantage of gentamicin, an aminoglycoside, is the association with nephrotoxicity and

ototoxicity, both of which are a result of elevated trough levels. Monitoring the serum
medication levels is an important action to minimize the risk of an adverse effect of gentamicin.

D. Administer the medicine with food.

Rationale: Gentamicin is given by IV or IM routes, and may be administered without regard to food.

55. A nurse is teaching a client who is taking metronidazole. Which of the following sense alterations should the nurse
include as an adverse effect of metronidazole?

A. Olfactory changes

Rationale: Metronidazole is more likely to cause peripheral neuropathy than changes in the client’s ability
to perceive odors.

B. Metallic taste

Rationale: Metronidazole is an antiprotozoal medication that treats giardiasis and trichomoniasis. It most
common adverse effects are headaches, nausea, dry mouth, and an unpleasant metallic taste
in their mouth.

C. Alterations in touch

Rationale: Metronidazole does not alter the perception of touch; however, it can cause peripheral
neuropathy, including paresthesias.

D. Hearing loss

Rationale: Metronidazole is more likely to cause vision disturbances than hearing loss.

56. A nurse in a mental health clinic is caring for a client who has bipolar disorder and a prescription for an
antipsychotic medication. The provider and nursing staff suspect the client is not adhering to his medication
therapy. Which of the following interventions should the staff use to encourage the client's adherence? (Select all
that apply.)

A. Perform mouth checks following the administration of the medication.

B. Provide for once-daily dosing.

C. Use sustained-release forms.

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D. Engage the client in conversation following medication administration.

E. Rotate staff that administer the medications.

Rationale: Perform mouth checks following the administration of medication is incorrect. Mouth checks
may not find pills that the client has hidden in his mouth.Provide for once-daily dosing is
correct. Once-daily dosing of medications simplifies the therapy, making it easier for the client
to comply.Use sustained-release forms is correct. Sustained-release forms remain in the
client's system longer, requiring less frequent dosing.Engage the client in conversation
following medication administration is correct. If the client is speaking, he will be less likely able
to hide the medication in his mouth.Rotate staff that administers the medications is incorrect.
Rotating treatment providers is an obstacle that increases the risk of a client's nonadherence to
therapy.

57. A nurse in a provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for
sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking
sildenafil?

A. Isosorbide

Rationale: Clients who are on nitrates including isosorbide and nitroglycerin preparations cannot take
sildenafil, because of the serious medication interaction. There is the possibility of sudden
death due to hypotension.

B. Phenytoin

Rationale: Phenytoin, an anticonvulsant, is not a contraindication for the prescription of sildenafil.

C. Metronidazole

Rationale: Metronidazole, an antifungal medication, is not a contraindication for the prescription of

sildenafil.

D. Prednisone

Rationale: Prednisone, a corticosteroid, is not a contraindication for the prescription of sildenafil.

58. A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4
hr as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which of the following
explanations should the nurse provide?

A. "The medication relieves nausea by promoting gastric emptying."

Rationale: Reglan is a gastrointestinal stimulant used to relieve nausea, vomiting, heartburn, stomach
pain, bloating, and a persistent feeling of fullness after meals. Reglan works by promoting
gastric emptying.

B. "The medication works by decreasing gastric acid secretions."

Rationale: Reglan does not decrease gastric acid secretions.

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C. "The medication relieves nausea by slowing peristalsis."

Rationale: Reglan does not slow peristalsis.

D. "The medication works by relaxing gastric muscles."

Rationale: Metoclopramide increases gastric muscle contraction.

59. A nurse is caring for a client who has developed gout. Which of the following medications should the nurse
prepare to administer?

A. Zolpidem

Rationale: Zolpidem is a sedative/hypnotic that is used for insomnia.

B. Alprazolam

Rationale: Alprazolam is a benzodiazepine that is prescribed to treat anxiety.

C. Spironolactone

Rationale: Spironolactone is an aldosterone antagonist that works as a potassium-sparing diuretic. It is

prescribed to treat edema and hypertension.

D. Allopurinol

Rationale: Allopurinol is a xanthene oxidase inhibitor that reduces uric acid synthesis. The medication is
prescribed to treat gout.

60. A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify
which of the following findings as an indication that the medication is effective?

A. A decrease in blood sugar

Rationale: Blood sugar level is not affected in diabetes insipidus.

B. A decrease in blood pressure

Rationale: Diabetes insipidus causes the loss of large amounts of urine, which can lead to hypotension.
An increase (or at least no further decrease) in blood pressure would be the desired response
to vasopressin.

C. A decrease in urine output

Rationale: The major manifestations of diabetes insipidus are excessive urination and extreme thirst.
Vasopressin is used to control frequent urination, increased thirst, and loss of water associated
with diabetes insipidus. A decreased urine output is the desired response.

D. A decrease in specific gravity

Rationale: An increase in specific gravity (indicating a more concentrated urine) would be the desired

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response of vasopressin.

61. A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has a
staphylococci infection. Available is clindamycin premixed in 50 mL 0.90% sodium chloride (NaCl). The nurse
should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing zero.)

100 mL/hr

Correct Rationale: STEP 1: What is the unit of measurement the nurse should calculate? mL/hr
STEP 2: What is the volume the nurse should infuse? 50 mL
STEP 3: What is the total infusion time? 30 min
STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal
hr)
60 min/30 min = 1 hr/X hr
X = 0.5 hr
STEP 5: Set up an equation and solve for X.
Volume (mL)/Time (hr) = X mL/hr
50 mL/0.5 hr = X mL/hr
X = 100
STEP 6: Round if necessary.
STEP 7: Reassess to determine whether the amount to administer makes sense. If the
prescription reads clindamycin 300 mg in 50 mL 90% NaCl by IV intermittent bolus to
infuse over 30 min, it makes sense to administer it at 100 mL/hr. The nurse should set the
IV pump to deliver clindamycin 300 mg in 50 mL 0.90% NaCl IV at 100 mL/hr.

InCorrect Rationale: STEP 1: What is the unit of measurement the nurse should calculate? mL/hr
STEP 2: What is the volume the nurse should infuse? 50 mL
STEP 3: What is the total infusion time? 30 min
STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal
hr)
60 min/30 min = 1 hr/X hr
X = 0.5 hr
STEP 5: Set up an equation and solve for X.
Volume (mL)/Time (hr) = X mL/hr
50 mL/0.5 hr = X mL/hr
X = 100
STEP 6: Round if necessary.
STEP 7: Reassess to determine whether the amount to administer makes sense. If the
prescription reads clindamycin 300 mg in 50 mL 90% NaCl by IV intermittent bolus to
infuse over 30 min, it makes sense to administer it at 100 mL/hr. The nurse should set
the IV pump to deliver clindamycin 300 mg in 50 mL 0.90% NaCl IV at 100 mL/hr.

62. A nurse is preparing to administer total parental nutrition (TPN) 1800 mL to infuse over 24 hr. The nurse should set
the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it
applies. Do not use a trailing zero.)

75 mL/hr

Correct Rationale: STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2:
What is the volume the nurse should infuse? 1800 mL STEP 3: What is the total infusion

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time? 24 hr STEP 4: Should the nurse convert the units of measurement? NoSTEP 5:
Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 1800 mL/24 hr = X
mL/hr X = 75 STEP 6: Round if necessary. STEP 7: Reassess to determine whether
the amount to administer makes sense. If the prescription reads TPN 1800 mL to infuse
over 24 hr, it makes sense to administer 75 mL/hr. The nurse should set the IV pump to
deliver TPN IV at 75 mL/hr.

InCorrect Rationale: STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2:
What is the volume the nurse should infuse? 1800 mL STEP 3: What is the total
infusion time? 24 hr STEP 4: Should the nurse convert the units of measurement?
NoSTEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr
1800 mL/24 hr = X mL/hr X = 75 STEP 6: Round if necessary. STEP 7: Reassess to
determine whether the amount to administer makes sense. If the prescription reads
TPN 1800 mL to infuse over 24 hr, it makes sense to administer 75 mL/hr. The nurse
should set the IV pump to deliver TPN IV at 75 mL/hr.

63. A nurse is caring for client who has sepsis and a prescription for vancomycin 1 g in 250 mL dextrose 5% (D5W)
over 2 hr by IV intermittent bolus. The nurse should set the IV pump to deliver how many mL/hr? (Round the
answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

125 mL/hr

Correct Rationale: STEP 1: What is the unit of measurement the nurse should calculate? mL/hr
STEP 2: What is the volume the nurse should infuse? 250 mL
STEP 3: What is the total infusion time? 2 hr
STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal
hr)
60 min/30 min = 1 hr/X hr
X = 0.5 hr
STEP 5: Set up an equation and solve for X.
Volume (mL)/Time (hr) = X mL/hr
250 mL/2 hr = X mL/hr
X = 125
STEP 6: Round if necessary.
STEP 7: Reassess to determine whether the amount to administer makes sense. If the
prescription reads vancomycin 1 g in 250 mL (D5W) over 2 hr by IV intermittent bolus, it
makes sense to administer 125 mL/hr. The nurse should set the IV pump to deliver
vancomycin 1 g in 250 mL D5W at 125 mL/hr.

64. A nurse is preparing to administer dextrose 5% in water (D5W) 150 mL IV to infuse over 3 hr. The drop factor of
the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 gtt/min

Correct Rationale: STEP 1: What is the unit of measurement the nurse should calculate? gtt/min STEP 2:
What is the volume the nurse should infuse? 150 mL STEP 3: What is the total infusion
time? 3 hr STEP 4: Should the nurse convert the units of measurement? Yes (min does
not equal hr) 1 hr/60 min = 3 hr/X min X = 180 min STEP 5: Set up an equation and
solve for X. Volume (mL)/Time (min) x drop factor (gtt/mL = X 150 mL/180 min x 10
gtt/mL = X gtt/min X = 8.3333 STEP 6: Round if necessary. 8.3333 = 8STEP 7:

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Reassess to determine whether the amount to administer makes sense. If the

prescription reads D5W 150 mL IV to infuse over 3 hr, it makes sense to administer 8
gtt/min. The nurse should set the manual IV infusion to deliver D5W IV at 8
gtt/min.Dimensional AnalysisSTEP 1: What is the unit of measurement the nurse should
calculate? gtt/min STEP 2: What is the quantity of the dose available? 10 gtt/min STEP
3: What is the total infusion time? 3 hr STEP 4: What is the volume the nurse should
infuse? 150 mLSTEP 5: Should the nurse convert the units of measurement? Yes (min
does not equal hr) 1 hr/60 minSTEP 6: Set up an equation and solve for X. X =
Quantity/1 mL x Conversion (hr)/Conversion (min) x Volume (mL)/Time (min) X gtt/min =
10 gtt/1 mL x 1 hr/60 min x 150 mL/3 hrX = 8.3333 STEP 7: Round if necessary. 8.3333
= 8STEP 8: Reassess to determine whether the amount to administer makes sense. If
the prescription reads D5W 150 mL IV to infuse over 3 hr, it makes sense to administer 8
gtt/min. The nurse should set the manual IV infusion to deliver D5W IV at 8 gtt/min.

InCorrect Rationale: STEP 1: What is the unit of measurement the nurse should calculate? gtt/min STEP 2:
What is the volume the nurse should infuse? 150 mL STEP 3: What is the total
infusion time? 3 hr STEP 4: Should the nurse convert the units of measurement? Yes
(min does not equal hr) 1 hr/60 min = 3 hr/X min X = 180 min STEP 5: Set up an
equation and solve for X. Volume (mL)/Time (min) x drop factor (gtt/mL = X 150
mL/180 min x 10 gtt/mL = X gtt/min X = 8.3333 STEP 6: Round if necessary. 8.3333 =
8STEP 7: Reassess to determine whether the amount to administer makes sense. If
the prescription reads D5W 150 mL IV to infuse over 3 hr, it makes sense to administer
8 gtt/min. The nurse should set the manual IV infusion to deliver D5W IV at 8
gtt/min.Dimensional AnalysisSTEP 1: What is the unit of measurement the nurse
should calculate? gtt/min STEP 2: What is the quantity of the dose available? 10
gtt/min STEP 3: What is the total infusion time? 3 hr STEP 4: What is the volume the
nurse should infuse? 150 mLSTEP 5: Should the nurse convert the units of
measurement? Yes (min does not equal hr) 1 hr/60 minSTEP 6: Set up an equation
and solve for X. X = Quantity/1 mL x Conversion (hr)/Conversion (min) x Volume
(mL)/Time (min) X gtt/min = 10 gtt/1 mL x 1 hr/60 min x 150 mL/3 hrX = 8.3333 STEP
7: Round if necessary. 8.3333 = 8STEP 8: Reassess to determine whether the amount
to administer makes sense. If the prescription reads D5W 150 mL IV to infuse over 3
hr, it makes sense to administer 8 gtt/min. The nurse should set the manual IV infusion
to deliver D5W IV at 8 gtt/min.

65. A nurse on a medical unit is planning care for an older adult client who takes several medications. Which of the
following prescribed medications places the client at risk for orthostatic hypotension? (Select all that apply.)

A. Furosemide

B. Telmisartan

C. Duloxetine

D. Clopidogrel

E. Atorvastatin

Rationale: Furosemide is correct. This medication is used to reduce edema and hypertension, and an
adverse effect is orthostatic hypotension.Telmisartan is correct. This medication is used to
control hypertension, and an adverse effect is orthostatic hypotension.Duloxetine is correct.
This medication is used to treat depression and anxiety disorder, and an adverse effect is
orthostatic hypotension.Clopidogrel is incorrect. This medication is used to reduce the risk of
MI and stroke and does not cause orthostatic hypotension.Atorvastatin is incorrect. This

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medication is used to decrease cholesterol and does not cause orthostatic hypotension.

66. A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol
hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the
provider?

A. The client has a history of hypothyroidism.

Rationale: Beta-adrenergic blockers may mask the symptoms of hyperthyroidism; therefore, they must be
used with caution in clients taking propranolol hydrochloride. Hypothyroidism is not a
contraindication for its use.

B. The client has a history of bronchial asthma.

Rationale: Beta-adrenergic blockers can cause bronchospasm in clients who have bronchial asthma;
therefore, this is a contraindication to its use and should be reported to the provider.

C. The client has a history of hypertension.

Rationale: Beta-adrenergic blockers, such as propranolol hydrochloride, may be used in combination with
other medications for the treatment of hypertension; therefore, this is not a contraindication to
the use of this medication.

D. The client has a history of migraine headaches.

Rationale: Beta-adrenergic blockers, such as propranolol hydrochloride, may be prescribed for the
prevention of migraine headaches; therefore, this is not a contraindication to the use of the
medication.

67. A home health nurse is assessing an older adult client who reports falling a couple of times over the past week.
Which of the following findings should the nurse suspect is contributing to the client's falls?

A. The client takes alprazolam.

Rationale: Alprazolam is a CNS depressant that can cause dizziness and orthostatic hypotension, which
can cause the client to lose his balance and fall.

B. The client has a nonslip bath mat in his shower.

Rationale: A nonslip bath mat should reduce the risk for the client to fall.

C. The client uses a raised toilet seat.

Rationale: A raised toilet seat should reduce the risk for the client to fall.

D. The client wears fitted slippers.

Rationale: Fitted and nonslip slippers should reduce the risk for the client to fall.

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68. A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a
need for further teaching?

A. "I have started taking ginger root to treat my joint stiffness."

Rationale: Ginger root can interfere with the blood clotting effect of warfarin and place the client at risk for
bleeding. This statement indicates the client needs further teaching.

B. "I take this medication at the same time each day."

Rationale: The client should take warfarin at the same time each day to maintain a stable blood level.

C. "I eat a green salad every night with dinner."

Rationale: Green leafy vegetables are a good source of vitamin K, which can interfere with the clotting
effects of warfarin. Clients who are taking warfarin do not need to restrict dietary vitamin K
intake but rather should maintain a consistent intake of vitamin K in order to control the
therapeutic effect of the medication.

D. "I had my INR checked three weeks ago."

Rationale: Clients who have been taking warfarin for more than 3 months should have their INR level
checked every 2 to 4 weeks.

69. A nurse is assessing a client prior to administering a seasonal influenza vaccine. The client says he read about an
influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize that which of
the following findings is a contraindication for the client receiving the live attenuated influenza vaccine (LAIV)?

A. The client's age is 62.

Rationale: Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is
contraindicated for this client. Pregnancy and immunocompromised status are also
contraindications.

B. The client smokes one pack of cigarettes a day

Rationale: Cigarette smoking is not a contraindication for receiving the LIAV.

C. The client has a history of myocardial infarction.

Rationale: A history of myocardial infarction is not a contraindication for receiving the LIAV.

D. The client has recently traveled to Europe.

Rationale: Recent travel to Europe is not a contraindication for receiving the LIAV.

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

A. Tinnitus

Rationale:

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Tinnitus and hearing loss are adverse effects of cisplatin.

B. Constipation

Rationale: Diarrhea is an adverse effect of cisplatin.

C. Hyperkalemia

Rationale: Hypokalemia is an adverse effect of cisplatin.

D. Weight gain

Rationale: Weight gain is an adverse effect of docetaxel due to fluid retention.

71. A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The
nurse should monitor the client for which of the following clinical manifestations?

A. Metabolic acidosis

Rationale: Hypermetabolism, such as with fever or exercise, can cause metabolic acidosis.

B. Metabolic alkalosis

Rationale: Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of
hydrochloric acid.

C. Respiratory acidosis

Rationale: Respiratory depression can cause respiratory acidosis.

D. Respiratory alkalosis

Rationale: Hyperventilation can cause respiratory alkalosis.

72. A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the
following assessments is the priority?

A. Pupil reaction

Rationale: The nurse should assess the client's pupils because morphine can cause miosis; however,
another assessment is the priority.

B. Urine output

Rationale: The nurse should assess the client's urine output because morphine can cause urinary
retention; however, another assessment is the priority.

C. Bowel sounds

Rationale: The nurse should assess the client's bowel sounds because morphine can cause constipation;
however, another assessment is the priority.

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D. Respiratory rate

Rationale: When using the airway, breathing, circulation approach to client care, the nurse should
determine the priority assessment is respiratory rate. Morphine can cause respiratory
depression. The nurse should withhold the medication and notify the prescriber if the client has
a respiratory rate less than 12/min.

73. A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The
nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin?

A. The client follows a low-fat diet to reduce cholesterol.

Rationale: A low-fat diet should not potentiate the action of warfarin.

B. The client drinks a glass of grapefruit juice every day.

Rationale: Grapefruit juice can interfere with the metabolism of statins.

C. The client sprinkles flax seeds on food 1 hr before taking the anticoagulant.

Rationale: Flax seed can affect the absorption of medications and should be taken 1 hr before or 2 hr after
medications.

D. The client uses garlic to lower cholesterol levels.

Rationale: The nurse should recognize that garlic can potentiate the action of the warfarin.

74. A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the
following foods as the best source of potassium?

A. Bananas

Rationale: The nurse should determine that bananas are the best food source to recommend because 1
cup of bananas contains 806 mg of potassium. In addition to the potassium supplements the
provider might prescribe, the client should increase his daily intake of foods that have high
potassium content, such as bananas, orange juice, and spinach.

B. Cooked carrots

Rationale: The nurse should recommend a different food because there is another choice that contains
more potassium

C. Cheddar cheese

Rationale: The nurse should recommend a different food because there is another choice that contains
more potassium

D. 2% milk

Rationale: The nurse should recommend a different food because there is another choice that contains
more potassium.

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75. A nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. Which of the following
instructions should the nurse include in the teaching?

A. Keep the open vial of insulin at room temperature.

Rationale: The client should keep the vial in use at room temperature to minimize tissue injury and to
reduce the risk for lipodystrophy.

B. Inject the insulin into a large muscle.

Rationale: The client should inject the medication into subcutaneous tissue.

C. Aspirate the medication prior to administration.

Rationale: It is not necessary for the nurse to aspirate the medication.

D. Administer the insulin in two separate injections.

Rationale: The client should mix compatible solutions, such as regular insulin and NPH insulin, to reduce
the need for an additional injection and reduce the risk for lipodystrophy.

76. A nurse is teaching a client who has iron deficiency anemia about ferrous sulfate. Which of the following
instructions should the nurse include in the teaching?

A. Take the ferrous sulfate at bedtime.

Rationale: The client should take the medication at least 1 hr before bedtime to reduce the risk of stomach
irritation.

B. Take the ferrous sulfate with an antacid.

Rationale: Antacids interfere with the absorption of ferrous sulfate.

C. Take the ferrous sulfate between meals.

Rationale: The client should take the medication between meals for optimal absorption.

D. Take the ferrous sulfate with yogurt.

Rationale: Dairy products interfere with the absorption of carbonyl iron; therefore, the client should not
take the medication with yogurt.

77. A nurse is caring for a female client who has rheumatoid arthritis and asks the nurse if it is safe for her to take
aspirin. The nurse should recognize which of the following findings in the client's history is a contraindication to this
medication?

A. Report of recent migraine headaches

Rationale: Increased intracranial pressure is a contraindication to aspirin. Migraine headaches are not a

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contraindication to the use of aspirin.

B. History of gastric ulcers

Rationale: Aspirin is contraindicated for clients who have a history of gastrointestinal bleeding and peptic
ulcer disease because it impedes platelet aggregation. An adverse effect of aspirin is gastric
bleeding.

C. Current diagnosis of glaucoma

Rationale: Nasal polyps are a contraindication to aspirin. Glaucoma is not a contraindication to the use of
aspirin.

D. Prior reports of amenorrhea

Rationale: Pregnancy is a contraindication to aspirin. Amenorrhea is not a contraindication to the use of

aspirin.

78. A nurse is providing discharge teaching for a client who has a new prescription for warfarin. Which of the following
instructions should the nurse include in the teaching?

A. Mild nosebleeds are common during initial treatment.

Rationale: Warfarin, an anticoagulant, increases the client's risk for bleeding. The nurse should instruct
the client to stop the medication and notify the provider for manifestations of bleeding.

B. Use an electric razor while on this medication.

Rationale: Warfarin, an anticoagulant, increases the client’s risk for bleeding. The nurse should teach the
client safety measures, such as using an electric razor, to decrease the risk for injury and
bleeding.

C. If a dose of the medication is missed, double the dose at the next scheduled time.

Rationale: Warfarin, an anticoagulant, should be taken at the same time each day and the client should
not adjust the dose. Doubling a dose increases the client's risk for bleeding.

D. Increase fiber intake to reduce the adverse effect of constipation.

Rationale: Warfarin can cause diarrhea.

79. A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions
should the nurse plan to take?

A. Check the unit of blood with an assistant personal (AP).

Rationale: Two RNs or an RN and a practical nurse (PN) (in certain institutions) can check a unit of blood
before it is transfused. This action is outside the scope of practice for an AP.

B. Premedicate the client with an antiemetic.

Rationale:

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The client might require premedication with an antipyretic, but not an antiemetic.

C. Plan to infuse the unit of blood over 6 hr.

Rationale: The unit of blood should infuse within 4 hr to reduce the risk for bacteria growth.

D. Remain with the client for the first 15 minutes of the transfusion.

Rationale: The nurse should remain with the client for the first 15 to 30 minutes of the transfusion to
monitor for a transfusion reaction, which occurs often during the first 50 mL of the transfusion.

80. A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed
RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the
following actions by the new nurse requires intervention by the charge nurse?

A. The nurse initiates an infusion of 0.9% sodium chloride.

Rationale: When suspecting a hemolytic reaction, the nurse should maintain IV access and blood volume
with an infusion of 0.9% sodium chloride.

B. The nurse collects a urine specimen.

Rationale: When suspecting a hemolytic reaction, the nurse should obtain a urine specimen to assess for
the presence of hemoglobin in the urine.

C. The nurse sends a blood specimen to the laboratory.

Rationale: When suspecting a hemolytic reaction, the nurse should obtain a blood specimen from the
client for laboratory analysis.

D. The nurse starts the transfusion of another unit of blood product.

Rationale: When suspecting a hemolytic reaction, the nurse should immediately stop the transfusion of all
blood products. The transfusion of additional products can increase the client's risk for further
complication.

81. A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following
actions should the plan to nurse take?

A. Leave the client 5 min after beginning the transfusion.

Rationale: The nurse should remain with the client for 15 to 30 min after the start of the transfusion to
monitor for a reaction, which usually occurs during the first 50 mL of the transfusion.

B. Infuse the transfusion at a rate of 200 mL/hr.

Rationale: The transfusion should infuse in 2 to 4 hr to prevent fluid overload.

C. Check the client's vital signs every hour during the transfusion.

Rationale: The nurse should check the client's vital signs every 15 min at the start of the transfusion, then

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every 1 hr to monitor for a transfusion reaction.

D. Flush the blood tubing with dextrose 5% in water.

Rationale: The nurse should flush the blood tubing with 0.9% sodium chloride to prevent hemolysis of the
blood.

82. A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a
manifestation of acute hemolytic reaction?

A. Client report of low back pain

Rationale: Manifestations of an acute hemolytic reaction include apprehension, tachypnea, hypotension,

chest pain, and lower back pain.

B. Client report of tinnitus

Rationale: Tinnitus is a manifestation of ototoxicity and is an adverse effect of aminoglycoside antibiotics.

C. A productive cough

Rationale: A cough is a manifestation of circulatory overload.

D. Distended neck veins

Rationale: Distended neck veins are a manifestation of circulatory overload.

83. A nurse is educating a group of clients about the contraindications of warfarin therapy. Which of the following
statements should the nurse include in the teaching?

A. "Clients who have glaucoma should not take warfarin."

Rationale: Liver disease is a contraindication for warfarin therapy.

B. "Clients who have rheumatoid arthritis should not take warfarin."

Rationale: Thrombocytopenia is a contraindication for warfarin therapy.

C. "Clients who are pregnant should not take warfarin."

Rationale: Warfarin therapy is contraindicated in the pregnant client because it crosses the placenta and
places the fetus at risk for bleeding.

D. "Clients who have hyperthyroidism should not take warfarin."

Rationale: Peptic ulcer disease is a contraindication for warfarin therapy

84. A nurse is caring for a client who is receiving a transfusion of packed red blood cells and suspects that the client

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is experiencing a hemolytic reaction. Which of the following interventions is the priority?

A. Collect a urine specimen.

Rationale: The client is at risk for hemoglobinuria and acute kidney injury due to hemolysis; however,
another action is the priority.

B. Administer 0.9% sodium chloride through the IV line.

Rationale: The client is at risk for hypotension and shock due to hemolysis, so it is important to keep an IV
open to administer fluids and medications; however, another action is the priority.

C. Stop the transfusion.

Rationale: The greatest risk to the client is injury due to further hemolysis; therefore, the priority action is
to stop the transfusion. When suspecting a hemolytic reaction, the priority action by the nurse is
to immediately stop the transfusion to prevent further hemolysis.

D. Notify the blood bank.

Rationale: The client is at risk for hypotension and shock due to hemolysis, and the nurse must notify the
blood bank to determine the cause of the hemolytic reaction; however, another action is the
priority.

85. A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following
actions should the nurse plan to take?

A. Administer the medication at 100 mg/min.

Rationale: The nurse should administer phenytoin IV slowly, not faster than 50 mg/min, to reduce the risk
of hypotension.

B. Administer a saline solution after injection.

Rationale: The nurse should flush the injection site with a saline solution after the injection of phenytoin to
reduce and prevent venous irritation.

C. Hold the injection if seizure activity is present.

Rationale: The nurse should administer phenytoin to prevent and to abort seizure activity.

D. Dilute the medication with dextrose 5% in water.

Rationale: The nurse should dilute phenytoin in 0.9% sodium chloride solution to prevent precipitation of
the medication.

86. A nurse is planning care for a client who has a detached retina and is preoperative for a surgical repair. The nurse
should prepare to administer which of the following medications?

A. Phenylephrine

Rationale:

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Mydriatic medications, such as phenylephrine, are used preoperatively to dilate pupils to

facilitate intraocular surgery.

B. Latanoprost

Rationale: Latanoprost is a prostaglandin used for the treatment of glaucoma.

C. Pilocarpine

Rationale: Pilocarpine is a miotic medication used for the treatment of glaucoma.

D. Timolol

Rationale: Timolol is a beta-blocker used for the treatment of glaucoma.

87. A nurse is assessing a client who is receiving a parental lipid infusion. Which of the following findings is a
manifestation of fat overload syndrome?

A. Elevated temperature

Rationale: An elevated temperature is an early manifestation of fat overload syndrome. The client is at
risk for coagulopathy and multi-organ system failure due to fat overload syndrome.

B. Hypertension

Rationale: Hypertension is a manifestation of fluid overload.

C. Peripheral edema

Rationale: Peripheral edema is a manifestation of fluid overload.

D. Erythema at the insertion site

Rationale: Erythema at the insertion site is a manifestation of infection and can indicate the need to
change infusion site.

88. A nurse is teaching a client who has a new prescription for aspirin to treat rheumatoid arthritis. The nurse should
include to monitor for which of the following adverse effects of this medication?

A. Constipation

Rationale: Aspirin can cause diarrhea.

B. Bleeding

Rationale: Aspirin can cause bleeding, tinnitus, gastric ulceration, nausea, and heartburn. The client
should monitor and report manifestations of bleeding, such as black tarry stools.

C. Blurred vision

Rationale: Aspirin can cause ototoxicity.

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D. Insomnia

Rationale: Aspirin can cause drowsiness.

89. A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the
following findings is a manifestation of digoxin toxicity?

A. Anorexia

Rationale: Anorexia, vomiting, confusion, headache, and vision changes are manifestations of digoxin
toxicity.

B. Ataxia

Rationale: Ataxia (lack of muscle coordination) is a manifestation of benzodiazepine toxicity.

C. Photosensitivity

Rationale: Digoxin toxicity causes halos around lights. Photosensitivity is a manifestation of NSAID
toxicity.

D. Jaundice

Rationale: Jaundice is a manifestation of sulfonylurea toxicity.

90. A nurse is teaching a client who has a new prescription for colesevelam to lower his low-density lipoprotein level.
Which of the following instructions should the nurse include?

A. "Take this medication 4 hr after other medications."

Rationale: The client should take this medication 4 hours after other medications to increase absorption of
the medication.

B. "Reduce fluid intake."

Rationale: The client should increase fiber and fluid intake to reduce the risk for constipation.

C. "Take this medication on an empty stomach."

Rationale: The client should take the medication with meals.

D. "Chew tablets before swallowing."

Rationale: The client should swallow tablets whole to increase absorption.

91. A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following
findings should indicate to the nurse that the medication is having a therapeutic effect?

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A. Systolic blood pressure is increased

Rationale: When dopamine has a therapeutic effect, it causes vasoconstriction peripherally and increases
systolic blood pressure.

B. Cardiac output is reduced

Rationale: A therapeutic effect of low-dose dopamine is increased cardiac output.

C. Apical heart rate is increased

Rationale: Tachycardia is an adverse effect, not a therapeutic effect, of dopamine.

D. Urine output is reduced

Rationale: A therapeutic effect of low-dose dopamine is increased urine output. Decreased urine output at
high doses is an adverse effect of dopamine.

92. A nurse is teaching a client who has a new prescription for sucralfate to treat a gastric ulcer. Which of the
following statements by the client indicates an understanding of the teaching?

A. "I will take this medication as needed to reduce pain."

Rationale: The client should take sucralfate on 4 times a day for 4 to 8 weeks to promote ulcer healing.

B. "I will reduce my fluid intake with this medication."

Rationale: The client should increase his fluid and fiber intake to prevent constipation.

C. "I will take this medication with an antacid."

Rationale: The client should wait 30 min between sucralfate and an antacid to increase absorption.

D. "I will take this medication 1 hour before meals and at bedtime."

Rationale: The client should take sucralfate on an empty stomach, 1 hr before each meal and at bedtime
to create a protective coating over the ulcer.

93. A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her
blood glucose level is above 200 mg/dL. Which of the following information should the nurse include?

A. Discard the NPH solution if it appears cloudy.

Rationale: The client should discard regular insulin if it appears cloudy.

B. Shake the insulin vigorously before loading the syringe.

Rationale: The client should gently roll the NPH insulin before loading the syringe to disperse the mixture
without creating bubbles.

C. Expect the NPH insulin to peak in 6 to 14 hr.

Rationale:

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NPH insulin is an intermediate-acting insulin. Its onset of action is 1 to 2 hr, peaking at 6 to 14

hr. Its duration of action is 16 to 24 hr. The client is at risk for hypoglycemia during the peak
time.

D. Freeze unopened insulin vials.

Rationale: The unopened insulin vials should be stored in the refrigerator.

94. A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports
low-back pain. Which of the following actions is the nurse's priority?

A. Stop the transfusion.

Rationale: The greatest risk to the client is injury due to further hemolysis; therefore, the priority action is
to stop the transfusion. When a hemolytic reaction is suspected, the priority action by the nurse
is to immediately stop the transfusion to prevent further hemolysis.

B. Collect a urine specimen.

Rationale: The client is at risk for hemoglobinuria and acute kidney injury due to hemolysis, so a urine
specimen is required; however, another action is the priority.

C. Notify the blood bank.

Rationale: The client is at risk for hypotension and shock due to hemolysis, and the nurse must notify the
blood bank to determine the cause of the hemolytic reaction; however, another action is the
priority.

D. Begin an infusion of 0.9% sodium chloride through new tubing.

Rationale: The client is at risk for hypotension and shock due to hemolysis, so it is important to keep an IV
open to administer fluids and medications; however, another action is the priority.

95. A nurse is teaching a client who has a new prescription for fluoxetine to treat depression. Which of the following
statements by the client indicates an understanding of the teaching?

A. "I should expect to feel better after 24 hours of starting this medication."

Rationale: The therapeutic effects of this medication can take 1 to 4 weeks to occur.

B. "I should not take this medicine with grapefruit juice."

Rationale: Grapefruit juice can interfere with the metabolism of lovastatin, but it does not affect fluoxetine.

C. "I'll take this medicine with food."

Rationale: The client can take fluoxetine with or without food.

D. "I'll take this medicine first thing in the morning."

Rationale: The client should take fluoxetine in the morning to reduce the risk for insomnia.

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96. A nurse is teaching a client who has a new prescription for docusate. Which of the following information should the
nurse include in the teaching?

A. "Do not take this medication before bedtime."

Rationale: The client can take this medication in the morning or in the evening before bedtime.

B. "Take the medication with a full glass of water."

Rationale: The nurse should instruct the client to take this medication with a full glass of water, unless
contraindicated, to reduce the risk for constipation.

C. "Expect abdominal pain with this medication."

Rationale: The client should notify the provider if abdominal pain occurs.

D. "Take this medication on an empty stomach."

Rationale: The client can take this medication with or without food.

97. A nurse is instructing the parents of a client who has a new prescription for methylphenidate. Which of the
following instructions should the nurse include?

A. Avoid activities that require alertness such as driving.

Rationale: The client should avoid driving and other activities that require alertness until the effects of this
medication are known.

B. Increase caffeine intake.

Rationale: The client should decrease caffeine intake to reduce the risk for excessive stimulation and
irritability.

C. Take this medication before bedtime.

Rationale: The client should take this medication 6 hr before sleep to reduce the risk for insomnia.

D. Reduce calorie intake.

Rationale: This medication can cause anorexia and weight loss.

98. A nurse is teaching a client who has a new prescription for aluminum hydroxide to treat heartburn. The nurse
should instruct the client to monitor for and report which of the following adverse reactions?

A. Constipation

Rationale: Aluminum hydroxide can cause constipation. The nurse should tell the client to increase fluid
and fiber intake to reduce the risk for constipation.

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B. Flatulence

Rationale: Calcium-containing antacids can cause flatulence.

C. Palpitations

Rationale: Cimetidine can cause dysrhythmias.

D. Headache

Rationale: Proton pump inhibitors can cause headaches.

99. A nurse is preparing to administer heparin to a client. Which of the following actions should the nurse plan to take?

A. Use a 22-gauge needle to inject the medication.

Rationale: The nurse should use a small needle, 25- or 26-gauge, to administer the heparin.

B. Use a 1-inch needle to inject the medication.

Rationale: The nurse should use a short needle, 3/8 inch or smaller, to administer the heparin.

C. Inject the medication into the abdomen above the level of the iliac crest.

Rationale: The nurse should inject the medication into the abdomen above the level of the iliac crest, at
least 2 inches from the umbilicus.

D. Massage the injection site after administration of the medication.

Rationale: The nurse should apply firm pressure without massage to the site for 1 to 2 min after
administration. Massaging the area after injecting heparin can cause bleeding.

100.A nurse is teaching a client how to draw up regular insulin and NPH insulin into the same syringe. Which of the
following instructions should the nurse include?

A. Draw up the NPH insulin into the syringe first.

Rationale: The nurse should teach the client to draw up the regular insulin into the syringe first.

B. Inject air into the regular insulin first.

Rationale: The nurse should teach the client to inject air into the NPH vial first.

C. Shake the NPH insulin until it is well mixed.

Rationale: The nurse should teach the client to roll the vial of NPH insulin between the palms of his
hands, not to shake it, to prevent forming bubbles, which can cause inaccurate dosage.

D. Discard regular insulin that appears cloudy.

Rationale: The nurse should teach the client to discard any regular insulin that appears cloudy, as

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regular insulin should be clear. NPH insulin has a cloudy appearance.

101.A nurse is assessing a client who is on long term omeprazole therapy. Which of the following findings should
indicate to the nurse the medication is effective?

A. Increased appetite

Rationale: Omeprazole does not increase appetite. Nausea is an adverse effect of this medication.

B. Regular bowel movements

Rationale: Omeprazole does not produce regular bowel movements. Diarrhea is an adverse effect of this
medication.

C. Absence of headache

Rationale: Omeprazole does not treat headaches. Headaches are an adverse effect of this medication.

D. Reduced dyspepsia

Rationale: Omeprazole, a proton pump inhibitor, reduces gastric acid secretion and treats duodenal and
gastric ulcers, prolonged dyspepsia, gastrointestinal reflux disease, and erosive esophagitis.

102.A nurse is teaching a client who has a new prescription for disulfiram. Which of the following information should
the nurse include in the teaching?

A. "Avoid grapefruit juice while taking this medication."

Rationale: Grapefruit juice can reduce the metabolism of carbamazepine.

B. "Do not crush this medication before swallowing."

Rationale: The client can crush disulfiram before swallowing.

C. "Do not drink alcohol while taking this medication."

Rationale: Disulfiram is a type of aversion therapy that helps maintain abstinence from alcohol. Drinking
alcohol while taking disulfiram can produce a life-threatening response that can include
palpitations, headache, and hypotension. Therapy must not begin until the client has
abstained from alcohol for at least 12 hr. The client should avoid all forms of alcohol including
cough syrups and after-shave lotions.

D. "Take this medication with food."

Rationale: Disulfiram is taken with or without food.

103.A nurse is reviewing the medication list for a client who has a new diagnosis of type 2 diabetes mellitus. The
nurse should recognize which of the following medications can cause glucose intolerance?

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A. Ranitidine

Rationale: Ranitidine can alter serum creatinine levels, but it does not affect blood glucose levels.

B. Guaifenesin

Rationale: Guaifenesin can cause drowsiness and dizziness, but does not alter blood glucose.

C. Prednisone

Rationale: Corticosteroids such as prednisone can cause glucose intolerance and hyperglycemia. The
client might require increased dosage of a hypoglycemic medication.

D. Atorvastatin

Rationale: Atorvastatin can interfere with thyroid function tests.

104.A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest
pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following
statements should the nurse make?

A. "A headache is an indication of an allergy to the medication."

Rationale: Allergic reactions typically manifest as itching and a rash, and if worsening, laryngeal edema
and bronchospasm.

B. "A headache is an expected adverse effect of the medication."

Rationale: The vasodilation nitroglycerin induces increases blood flow to the head and typically results in
a headache.

C. "A headache indicates tolerance to the medication."

Rationale: With tolerance, the client needs more of the medication to achieve a therapeutic response. A
headache is not a sign of this phenomenon.

D. "A headache is likely due to the anxiety about the chest pain."

Rationale: This is a nontherapeutic communication technique and offers the nurse's opinion about the
cause of the headache rather than a factual statement.

105.A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris.
Which of the following instructions should the nurse include in the teaching?

A. Apply a new transdermal patch once a week.

Rationale: The client should apply a new patch each day, not once a week.

B. Apply the transdermal patch in the morning.

Rationale: The client should apply the patch every morning and leave it in place for a 12 to 14 hr, then

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remove it in the evening.

C. Apply the transdermal patch in the same location as the previous patch.

Rationale: The client should rotate the sites used for patch placement to avoid areas of local skin
irritation.

D. Apply a new transdermal patch when chest pain is experienced.

Rationale: The transdermal route of nitroglycerin has a delayed onset of action, making it suitable for
prophylaxis use but not for immediate relief of chest pain.

106.A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction
during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of
the following allergic responses?

A. Urticaria

Rationale: For clients who have previously had allergic reactions to blood transfusions, administering an
antihistamine such as diphenhydramine prior to the transfusion might prevent future reactions.
Allergic reactions typically include urticaria (hives).

B. Fever

Rationale: An antihistamine will not prevent a febrile, non-hemolytic reaction to a blood transfusion. A
possible preventive measure is transfusing leucocyte-poor blood products to avoid
sensitization to the donor's WBC.

C. Fluid overload

Rationale: An antihistamine will not prevent fluid overload. Transfusing the blood product slowly and not
exceeding the volume that is necessary can reduce this risk.

D. Hemolysis

Rationale: An antihistamine will not prevent hemolysis, which results from incompatibility between the
donor and the recipient.

107.A nurse is preparing to administer nalbuphine to a postoperative client who is experiencing pain. The nurse
should monitor the client for which of the following potential adverse effects of this medication?

A. Miosis

Rationale: Adverse effects of nalbuphine include visual disturbances such as miosis, blurred vision, and
diplopia.

B. Joint pain

Rationale: Nalbuphine is unlikely to cause joint pain; however, it can cause headache and abdominal
cramps.

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C. Diarrhea

Rationale: Nalbuphine can cause constipation, cramps, and abdominal pain, but it does not have
diarrhea as an adverse effect.

D. Oliguria

Rationale: Nalbuphine is unlikely to cause oliguria; however, it can cause urinary urgency.

108.A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). The
nurse should plan to administer the client's PRN bethanechol when the client reports which of the following
manifestations?

A. Bladder spasms

Rationale: Antispasmodic medications, not bethanechol, help control bladder spasms after a TURP.

B. Severe pain.

Rationale: Analgesic medications, not bethanechol, help relieve severe pain after a TURP.

C. An inability to void

Rationale: Bethanechol is a cholinergic medication that stimulates the parasympathetic nervous system,
thus improving the tone and motility of the smooth muscles of the urinary tract enough to
initiate urination.

D. Frequent episodes of painful urination

Rationale: Analgesic medications, or antibiotics if infection is the cause, help relieve frequent episodes of
painful urination after a TURP.

109.A nurse is teaching a client who has a duodenal ulcer about his new prescription for cimetidine. The nurse should
include which of the following instructions in the teaching?

A. "Take the medication with an antacid to minimize stomach upset."

Rationale: Clients should not take this medication within 1 hr of taking an antacid because the antacid
will interfere with the absorption of cimetidine.

B. "Your doctor might need to reduce your theophylline dose while taking this medication."

Rationale: The nurse should instruct the client that the provider might need to reduce his theophylline
dose due to the possibility of increased medication levels.

C. "Take the medication on an empty stomach for better absorption."

Rationale: Clients should take cimetidine with food to minimize gastric irritation.

D. "You should plan to take this medication for at least 6 months."

Rationale:

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The nurse should instruct the client that he should plan to take cimetidine for short-term
treatment of a duodenal ulcer, which will be approximately 4 to 6 weeks.

110.A nurse is reviewing the laboratory results of a client who has liver failure with ascites and is receiving
spironolactone. Which of the following findings should the nurse expect?

A. Decreased sodium level

Rationale: The nurse should expect a decreased sodium level. Spironolactone is a potassium-sparing
diuretic that inhibits the action of aldosterone, resulting in an increased excretion of sodium.

B. Decreased phosphate level

Rationale: The nurse should not expect a decreased phosphate level. Spironolactone inhibits the action
of aldosterone, resulting in the retention of phosphate.

C. Decreased potassium level

Rationale: The nurse should not expect a decreased potassium level. Spironolactone is a
potassium-sparing diuretic that inhibits the action of aldosterone, resulting in the retention of
potassium.

D. Decreased chloride level

Rationale: The nurse should not expect a decreased chloride level. Spironolactone is a
potassium-sparing diuretic that inhibits the action of aldosterone, resulting in the retention of
chloride.

111.A nurse is assessing a client who has systemic lupus erythematosus and is taking hydroxychloroquine. The
nurse should report which of the following adverse effects to the provider immediately?

A. Diarrhea

Rationale: Diarrhea is a potential adverse effect of hydroxychloroquine that the nurse should report to the
provider; however, it is not the priority finding.

B. Blurred vision

Rationale: When using the urgent vs non-urgent approach to client care, the nurse should determine that
the priority finding to report to the provider is blurred vision, as this is a manifestation of
hydroxychloroquine toxicity and can be an indication of retinal damage.

C. Pruritus

Rationale: Pruritus is a potential adverse effect of hydroxychloroquine that the nurse should report to the
provider; however, it is not the priority finding.

D. Fatigue

Rationale: Fatigue is a potential adverse effect of hydroxychloroquine that the nurse should report to the
provider; however, it is not the priority finding.

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112.A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of
the following medications should the nurse have available to reverse heparin's effects?

A. Vitamin K

Rationale: Vitamin K reverses the effects of warfarin, not heparin, by promoting the synthesis of
coagulation factors VI, IX, X, and prothrombin.

B. Protamine sulfate

Rationale: Protamine sulfate reverses the effects of heparin by binding with heparin to form a
heparin-protamine complex that has no anticoagulant properties.

C. Acetylcysteine

Rationale: Acetylcysteine, a mucolytic, reduces the risk of hepatotoxicity after acetaminophen overdose.
It does not reverse the effects of heparin toxicity.

D. Deferasirox

Rationale: A chelating agent such as deferasirox binds to iron to reduce iron toxicity from supplemental
iron therapy. It does not reverse the effects of heparin toxicity.

113.A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the
client for which of the following electrolyte imbalances?

A. Hypernatremia

Rationale: The nurse should monitor the client who is receiving IV furosemide for hyponatremia.

B. Hyperuricemia

Rationale: The nurse should monitor the client who is receiving IV furosemide for hyperuricemia. The
nurse should instruct the client to notify the provider for any tenderness or swelling of the
joints.

C. Hypercalcemia

Rationale: The nurse should monitor the client who is receiving IV furosemide for hypocalcemia.

D. Hyperchloremia

Rationale: The nurse should monitor the client who is receiving IV furosemide for hypochloremia.

114.A nurse is teaching a client who has multiple sclerosis about a new prescription for baclofen. Which of the
following instructions should the nurse include in the teaching?

A. "Do not take antihistamines with this medication."

Rationale:

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The nurse should instruct the client not to take antihistamines while taking baclofen.
Antihistamines will intensity the depressant effects of baclofen.

B. "Take the medication on an empty stomach."

Rationale: The medication causes nausea and gastrointestinal distress, so the client should take it with
milk or meals.

C. "Stop taking the medication immediately for a headache."

Rationale: Abrupt withdrawal of baclofen, a centrally acting muscle relaxant, might cause seizures, fever,
and hypotension. A better alternative is to treat the headache, which can have many other
causes, and see if it resolves as medication therapy with baclofen continues.

D. "Expect to develop diarrhea initially."

Rationale: Baclofen is more likely to cause constipation than diarrhea.

115.A nurse is teaching a client who has a new prescription for diazepam. Which of the following information should
the nurse include in the teaching?

A. Diazepam can cause drowsiness.

Rationale: Diazepam has sedative properties, so the client should not engage in potentially hazardous
activities after receiving diazepam.

B. This medication must be swallowed whole.

Rationale: Diazepam can be crushed and taken with food if the client is unable to swallow the medication
whole.

C. It is important to avoid foods that contain tyramine.

Rationale: Clients who take monoamine oxidase inhibitors must avoid foods that contain tyramine.

D. Grapefruit juice inactivates this medication.

Rationale: Although grapefruit juice can affect the metabolism of many medications, generally raising
their blood levels, diazepam is not among them.

116.A nurse is reviewing discharge instructions with a client who has rheumatoid arthritis and a new prescription for
prednisone. Which of the following statements by the client indicates an understanding of the teaching?

A. "I should take my flu vaccine within one week of starting this medication."

Rationale: The nurse should instruct the client to avoid taking vaccines while taking prednisone. This
medication can decrease antibody response to the vaccine and can increase the risk of
infection from live virus vaccines.

B. "I can expect a sore throat for the first week after starting this medication."

Rationale:

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The nurse should instruct the client to report manifestations such as a sore throat or fever to
the provider if they occur, as these may indicate infection.

C. "I should eat more bananas while taking this medication."

Rationale: The nurse should instruct the client to eat more potassium-rich foods such as bananas and
citrus fruits while taking this medication. Prednisone can cause a loss of potassium, and the
nurse should instruct the about the manifestations of hypokalemia such as muscle weakness
and cramping and to notify the provider should these occur.

D. "I should take aspirin for minor aches and pains while taking this medication."

Rationale: The nurse should instruct the client not to take salicylates or NSAIDs for pain because these
medications can increase the risk of gastric ulceration.

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