180 questions and correct answers with rationales [NEW
EDITION 2026]
,
, 1. A nurse on an inpatient unit is reviewing the medical record of a client who has
bipolar disorder and has been taking lithium carbonate.
Day 1 (1600): Blood pressure 114/64 mm Hg, Pulse 84/min, Lithium level 0.8 mEq/L.
Day 2 (0800): Blood pressure 92/56 mm Hg, Pulse 62/min, Lithium level 2.1 mEq/L.
The client is experiencing coarse hand tremors, vomiting, and diarrhea.
Which of the following actions should the nurse take first?
A) Administer the next scheduled dose of lithium carbonate.
B) Hold the medication and notify the provider immediately. (Correct Answer)
C) Encourage the client to increase fluid intake to 3,000 mL/day.
D) Request a repeat lithium level to be drawn in 4 hours.
✔️ Rationale: A lithium level of 2.1 mEq/L indicates severe lithium toxicity (therapeutic
range is 0.6 to 1.2 mEq/L). Clinical manifestations include severe gastrointestinal upset,
coarse hand tremors, hypotension, and bradycardia. The immediate priority action is to
stop the medication to prevent further toxicity and complications, such as seizures or
renal failure.
2. A nurse is admitting a client who is experiencing a severe panic attack. Which
of the following interventions should the nurse implement first?
A) Teach the client deep-breathing relaxation techniques.
B) Administer an oral dose of buspirone.
C) Stay with the client and use short, simple sentences. (Correct Answer)
D) Ask the client to identify the trigger of the panic attack.
✔️ Rationale: During a severe panic attack, the client's anxiety level impairs their ability
to process complex information or learn new skills. Staying with the client provides a
sense of security and safety. Using short, simple sentences ensures the client can
comprehend the communication without increasing cognitive burden.
3. A nurse is caring for a client who has schizophrenia and is experiencing
auditory hallucinations telling them to harm others. Which of the following is the
priority nursing action?
A) Ask the client directly what the voices are saying. (Correct Answer)
B) Administer a PRN dose of haloperidol immediately.
C) Tell the client that the voices are not real.
D) Dismiss the client's claims and redirect to a group activity.