NCLEX Medication Administration Review –
100 Q&A with Rationales
1. A nurse is administering digoxin to a client with heart failure. Which
of the following should the nurse assess before administration?
a) Blood pressure
b) Heart rate
c) Respiratory rate
d) Temperature
Answer: b) Heart rate
Rationale: Digoxin can slow the heart rate. The nurse should hold the
medication if the heart rate is below 60 bpm in adults.
2. A client is prescribed metformin for type 2 diabetes. Which
instruction is important for the nurse to provide?
a) Avoid sunlight
b) Take with meals
c) Increase potassium intake
d) Stop if blood sugar is normal
Answer: b) Take with meals
Rationale: Metformin should be taken with meals to reduce
gastrointestinal side effects such as nausea and diarrhea.
3. A nurse is giving an intramuscular injection. Which site is safest for
a 2 mL medication in an adult?
a) Deltoid
b) Ventrogluteal
,c) Dorsogluteal
d) Vastus lateralis
Answer: b) Ventrogluteal
Rationale: The ventrogluteal site is preferred for larger volumes and is
away from major nerves and blood vessels.
4. A client receiving heparin therapy develops black, tarry stools.
What is the priority nursing action?
a) Continue heparin
b) Notify the provider
c) Encourage fluid intake
d) Assess for leg swelling
Answer: b) Notify the provider
Rationale: Black, tarry stools indicate gastrointestinal bleeding, a
serious complication of heparin therapy that requires immediate
attention.
5. Which route provides the fastest onset of action for a medication?
a) Oral
b) Subcutaneous
c) Intravenous
d) Intramuscular
Answer: c) Intravenous
Rationale: IV administration delivers the medication directly into the
bloodstream, providing immediate effect.
,6. A nurse is preparing to administer morphine IV to a client in pain.
What is a priority nursing intervention?
a) Monitor blood glucose
b) Assess respiratory rate
c) Check bowel sounds
d) Assess temperature
Answer: b) Assess respiratory rate
Rationale: Morphine can cause respiratory depression, so monitoring
the respiratory rate before and after administration is essential.
7. A client is prescribed warfarin. Which laboratory test is used to
monitor therapy?
a) aPTT
b) INR
c) Creatinine
d) Hemoglobin
Answer: b) INR
Rationale: INR (International Normalized Ratio) is used to monitor
warfarin effectiveness and ensure the dose is therapeutic but not
excessive.
8. The nurse is preparing to administer an antibiotic via IV infusion.
Which action is most important?
a) Assess vital signs
b) Review allergies
c) Check capillary refill
d) Encourage ambulation
, Answer: b) Review allergies
Rationale: Assessing for drug allergies is critical before administering
any medication, especially antibiotics, to prevent severe allergic
reactions.
9. A client reports difficulty swallowing pills. What is the best nursing
action?
a) Crush all pills and mix with water
b) Offer liquid formulations if available
c) Encourage the client to swallow anyway
d) Hold all medications
Answer: b) Offer liquid formulations if available
Rationale: Liquid formulations are safer for clients with swallowing
difficulties and reduce the risk of choking or aspiration.
10. A nurse is giving a subcutaneous insulin injection. What is the
appropriate needle length?
a) 25–27 gauge, 1 inch
b) 20 gauge, 2 inches
c) 22 gauge, 1.5 inches
d) 25–30 gauge, 3/8–5/8 inch
Answer: d) 25–30 gauge, 3/8–5/8 inch
Rationale: Short, fine needles are appropriate for subcutaneous
injections to reduce pain and ensure proper absorption.
11. Which statement indicates a client understands proper use of a
metered-dose inhaler?
100 Q&A with Rationales
1. A nurse is administering digoxin to a client with heart failure. Which
of the following should the nurse assess before administration?
a) Blood pressure
b) Heart rate
c) Respiratory rate
d) Temperature
Answer: b) Heart rate
Rationale: Digoxin can slow the heart rate. The nurse should hold the
medication if the heart rate is below 60 bpm in adults.
2. A client is prescribed metformin for type 2 diabetes. Which
instruction is important for the nurse to provide?
a) Avoid sunlight
b) Take with meals
c) Increase potassium intake
d) Stop if blood sugar is normal
Answer: b) Take with meals
Rationale: Metformin should be taken with meals to reduce
gastrointestinal side effects such as nausea and diarrhea.
3. A nurse is giving an intramuscular injection. Which site is safest for
a 2 mL medication in an adult?
a) Deltoid
b) Ventrogluteal
,c) Dorsogluteal
d) Vastus lateralis
Answer: b) Ventrogluteal
Rationale: The ventrogluteal site is preferred for larger volumes and is
away from major nerves and blood vessels.
4. A client receiving heparin therapy develops black, tarry stools.
What is the priority nursing action?
a) Continue heparin
b) Notify the provider
c) Encourage fluid intake
d) Assess for leg swelling
Answer: b) Notify the provider
Rationale: Black, tarry stools indicate gastrointestinal bleeding, a
serious complication of heparin therapy that requires immediate
attention.
5. Which route provides the fastest onset of action for a medication?
a) Oral
b) Subcutaneous
c) Intravenous
d) Intramuscular
Answer: c) Intravenous
Rationale: IV administration delivers the medication directly into the
bloodstream, providing immediate effect.
,6. A nurse is preparing to administer morphine IV to a client in pain.
What is a priority nursing intervention?
a) Monitor blood glucose
b) Assess respiratory rate
c) Check bowel sounds
d) Assess temperature
Answer: b) Assess respiratory rate
Rationale: Morphine can cause respiratory depression, so monitoring
the respiratory rate before and after administration is essential.
7. A client is prescribed warfarin. Which laboratory test is used to
monitor therapy?
a) aPTT
b) INR
c) Creatinine
d) Hemoglobin
Answer: b) INR
Rationale: INR (International Normalized Ratio) is used to monitor
warfarin effectiveness and ensure the dose is therapeutic but not
excessive.
8. The nurse is preparing to administer an antibiotic via IV infusion.
Which action is most important?
a) Assess vital signs
b) Review allergies
c) Check capillary refill
d) Encourage ambulation
, Answer: b) Review allergies
Rationale: Assessing for drug allergies is critical before administering
any medication, especially antibiotics, to prevent severe allergic
reactions.
9. A client reports difficulty swallowing pills. What is the best nursing
action?
a) Crush all pills and mix with water
b) Offer liquid formulations if available
c) Encourage the client to swallow anyway
d) Hold all medications
Answer: b) Offer liquid formulations if available
Rationale: Liquid formulations are safer for clients with swallowing
difficulties and reduce the risk of choking or aspiration.
10. A nurse is giving a subcutaneous insulin injection. What is the
appropriate needle length?
a) 25–27 gauge, 1 inch
b) 20 gauge, 2 inches
c) 22 gauge, 1.5 inches
d) 25–30 gauge, 3/8–5/8 inch
Answer: d) 25–30 gauge, 3/8–5/8 inch
Rationale: Short, fine needles are appropriate for subcutaneous
injections to reduce pain and ensure proper absorption.
11. Which statement indicates a client understands proper use of a
metered-dose inhaler?
