ACTUAL EXAM QUESTIONS WITH DETAILED
VERIFIED ANSWERS /A+ GRADE ASSURED
1) A nurse is reviewing he laboratory results of a client who has a prescription for
sodium polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should
the nurse report tothe provider?
a. Creatinine 0.72 mg/dL
b. Sodium 138 mEq/L
c. Magnesium 2 mEq/L
d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassium level greater than 5.0
mEq/L) increases the client risk for fatal cardiac dysrhythmias. Kayexalate is
used to decrease theserum potassium level, so the PN should monitor the client's
serum potassium level
2) A nurse is assessing a client who is receiving intravenous therapy. The nurse
should identifywhich of the following findings as a manifestation of fluid volume
excess?
a. Decreased bowel sounds
b. Distended neck veins
c. Bilateral muscle weakness
d. Thread pulse
3) A nurse is caring for a client who has hyponatremia and is receiving an infusion of a
prescribedhypertonic solution. Which of the following findings should indicate to the
nurse that the treatment is effective?
a. Absent Chvostek’s sign
b. Improved cognition
c. Decreased vomiting
d. Cardiac arrhythmias absent
4) A nurse is teaching a client who has a new prescription for a nitroglycerin
transdermal patch.Which of the following instructions should the nurse include?
a. “Discontinue the patch if you experience a headache.”
b. “Apply a new patch if you have chest pain.”
c. “Cover the patch with dry gauze when taking a shower.”
d. “Remove the patch prior to going to bed.”
5) A nurse is caring for a client who has tuberculosis and is taking isoniazid and
rifampin. Which ofthe following outcomes indicates that the client is adhering to the
medication regimen?
a. The client has a negative sputum culture
b. The client tests negative for HIV
c. The client has a positive purified protein derivative test
d. The client’s liver function test results are within the expected reference range
6) A client is caring for a client who develops an anaphylactic reaction to IV
,administration. Afterassessing the client’s respiratory status and stopping the
medication infusion. Which of the following actions should the nurse take next?
a. Replace the infusion with 0.9% sodium chloride
b. Give diphenhydramine IM
c. Elevate the client’s legs and feet
d. Administer epinephrine IM
,7) A nurse is caring for a client who is taking sertraline and reports a desire to begin
taking supplements. Which of the following supplements should the nurse advise
the client to avoid?
a. St. John’s Wort
b. Ginger root
c. Black cohosh
d. Coenzyme Q10
8) A nurse is caring for a client who has heart failure and a new prescription for lisinopril.
For whichof the following adverse effects should the nurse monitor when
administering lisinopril?
a. Bradycardia
b. Hypokalemia
c. Tinnitus
d. Hypotension
9) *A nurse is assessing a client who is receiving heparin IV continuous IV. The client
has an PPT of90 seconds. They should monitor the client for which of the following
changes in their vital signs?
a. Decreased temperature
b. Increased pulse rate
c. Decreased respiratory rate
d. Increased blood pressure
10) A nurse is preparing to administer medication to a client and discovers a medication
error. The nurse should recognize that which of the following staff members is
responsible for completingan incident report?
a. The quality improvement committee
b. The nurse who identifies the error
c. The nurse who caused the error
d. The charge nurse
11) A nurse is planning care for a client who is receiving morphine via continuous
epidural infusion.The nurse should monitor the client for which of the following?
a. Pruritus – Sign of allergic reaction to morphine
b. Cough
c. Tachypnea
d. Gastric bleeding
12) A nurse is preparing to administer digoxin orally to a client. Identify the sequence of
steps thenurse should take. (Move the steps into the box on the right, placing them in
the order of performance. Use all the steps.)
a. Obtain the client’s apical heart rate
b. Remove the medication from the dispensing
systemc. Open the medication package
d. Compare the client’s wristband to the medication administration
recorde. Document administration of the medication
, 13) A nurse is reviewing the medical record of an adult client who has a fever and a
prescription foracetaminophen. Which of the following findings should the nurse
identify as a contraindicationfor receiving this medication?
a. Alcohol use disorder
b. Chronic kidney disease
c. Hepatitis B vaccine within the last week
d. Diabetes mellitus
14) A home health nurse is visiting a client who has heart failure and a prescription for
furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last
visit 2 days ago. Whichof the following actions should the nurse take first?
a. Encourage the client to dangle the legs while sitting in a chair
b. Teach the client about foods low in sodium
c. Determine medication adherence by the client
d. Notify the provider of the client’s weight gain
15) A nurse is preparing to administer the initial dose of penicillin G IM to a client. The
nurse shouldmonitor for which of the following as an indication of an allergic
reaction following the injection?
a. Urticaria
b. Bradycardia
c. Pallor
d. Dyspepsia
16) A nurse is teaching a client who has angina a new prescription for sublingual
nitroglycerintablets. Which of the following instructions should the nurse
include in the teaching?
a. “Discard any tablets you do not use every 6 months.”
b. “Take one tablet each morning 30 minutes prior to eating.”
c. “Keep the tablets at room temperature in their original glass bottle.”
d. “Place the tablet between your cheek and gum to dissolve.”
17) A nurse is providing teaching to a client who has a new prescription for
theophylline, a sustained-released capsule. Which of the following statements
by the client indicates anunderstanding of the teaching?
a. “I can take my medication in the morning with my coffee.”
b. “I may sprinkle the medication in applesauce.”
c. “I should limit my fluid intake while on this medication.”
d. “I will need to have blood levels drawn.”
18) A nurse is mixing regular insulin and NPH insulin in the same syringe prior to
administering it toclient who has diabetes mellitus following actions should the
nurse take first?
a. Withdraw the regular insulin from the viral
b. Withdraw the NPH insulin form
the vialc. Inject air into the NPH
vial
d. Inject air into the regular insulin vial
19) A nurse is preparing to administer subcutaneous heparin to a client. Which of the