|Rationales
1. A nurse is preparing to administer digoxin to a client with heart failure. Which
of the following findings should the nurse identify as a manifestation of digoxin
toxicity?
A. Constipation
B. Yellow-tinged vision
C. Increased appetite
D. Tachycardia
Answer: B
Rationale: Manifestations of digoxin toxicity include gastrointestinal disturbances like
nausea and vomiting, neurological symptoms, and visual changes such as yellow-tinged
vision or halos around lights.
2. A client is prescribed furosemide for the treatment of peripheral edema.
Which of the following lab values should the nurse prioritize monitoring?
A. Serum sodium
B. Serum calcium
C. Serum glucose
D. Serum potassium
Answer: D
Rationale: Furosemide is a loop diuretic that causes the excretion of potassium.
Hypokalemia is a significant risk and requires close monitoring.
,3. A nurse is teaching a client who has a new prescription for warfarin. Which of
the following instructions should the nurse include?
A. Increase intake of leafy green vegetables
B. Use a hard-bristle toothbrush
C. Carry a medical alert ID card
D. Take aspirin for minor headaches
Answer: C
Rationale: Clients on anticoagulants like warfarin should carry medical identification.
They should maintain a consistent intake of Vitamin K (not increase it) and avoid aspirin or
hard toothbrushes due to bleeding risks.
4. Which of the following medications is used as the antidote for heparin
toxicity?
A. Vitamin K
B. Naloxone
C. Protamine sulfate
D. Acetylcysteine
Answer: C
Rationale: Protamine sulfate is the specific antidote used to reverse the effects of heparin.
Vitamin K is for warfarin, naloxone for opioids, and acetylcysteine for acetaminophen.
5. A nurse is administering albuterol to a client with asthma. The nurse should
monitor for which of the following adverse effects?
A. Bradycardia
B. Lethargy
C. Tachycardia
D. Hypoglycemia
Answer: C
, Rationale: Albuterol is a sympathomimetic bronchodilator that often causes stimulation of
the beta-1 receptors in the heart, leading to tachycardia and tremors.
6. A nurse is caring for a client who is taking spironolactone. Which of the
following food choices should the client be instructed to avoid?
A. Salt substitutes
B. White bread
C. Apples
D. Chicken breast
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic. Salt substitutes often contain
potassium chloride instead of sodium chloride, which increases the risk of hyperkalemia.
7. A client with angina is taught how to use sublingual nitroglycerin. How many
minutes should the client wait between doses?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
Answer: B
Rationale: Sublingual nitroglycerin should be taken every 5 minutes for up to 3 doses if
chest pain persists. If pain is not relieved after the first dose, 911 should be called.