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1.
A nurse administers lisinopril to a client with hypertension. Which assessment
finding requires immediate follow-up?
A. Dry cough
B. Potassium level of 5.8 mEq/L
C. Blood pressure of 118/76 mm Hg
D. Reports of mild dizziness on standing
Correct Answer: B
Rationale:
ACE inhibitors can cause hyperkalemia. A potassium level of 5.8 mEq/L is
potentially life-threatening and requires immediate intervention.
,2.
A client receiving IV morphine develops shallow respirations and pinpoint pupils.
Which medication should the nurse anticipate administering?
A. Naloxone
B. Flumazenil
C. Atropine
D. Protamine sulfate
Correct Answer: A
Rationale:
Naloxone is an opioid antagonist used to reverse opioid-induced respiratory
depression.
3.
The provider orders heparin 18 units/kg/hr for a client weighing 70 kg. How many
units per hour should the nurse administer?
A. 980 units/hr
B. 1,120 units/hr
C. 1,260 units/hr
D. 1,400 units/hr
Correct Answer: C
Rationale:
18 × 70 = 1,260 units/hr.
,4.
A client taking warfarin reports black, tarry stools. What is the nurse’s priority
action?
A. Administer vitamin K
B. Hold the next dose of warfarin
C. Notify the provider immediately
D. Obtain an INR level
Correct Answer: C
Rationale:
Melena indicates active gastrointestinal bleeding, a medical emergency requiring
immediate provider notification.
5.
Which instruction is most important for a client prescribed nitroglycerin sublingual
tablets?
A. Store tablets in a weekly pill organizer
B. Swallow tablets with water
C. Sit or lie down before taking the medication
D. Take the medication after meals
Correct Answer: C
Rationale:
Nitroglycerin can cause orthostatic hypotension. Sitting or lying down prevents
injury from syncope.
, 6.
A nurse is caring for a client with asthma who is prescribed propranolol. What
action should the nurse take?
A. Administer the medication as prescribed
B. Hold the medication and notify the provider
C. Monitor blood glucose levels closely
D. Administer with a bronchodilator
Correct Answer: B
Rationale:
Propranolol is a nonselective beta-blocker that can trigger bronchoconstriction
and is contraindicated in asthma.
7.
Which laboratory value should be monitored most closely in a client receiving
furosemide?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
Correct Answer: B
Rationale:
Loop diuretics cause potassium wasting, increasing the risk for hypokalemia and
cardiac dysrhythmias.