1. A nurse is caring for a client who is taking phenytoin, for which of the following adverse effects should the nurse
monitor and report to the
... [Show More] provider
a. Cognitive impairment
b. Tachycardia
c. Elevated blood pressure (HYPOTENSION and DYSRHYTHMIAS)
d. Tinnitus
Phenytoin (Dilantin) - Anticonvulsant. monitor for any manifestations of CNS effects (such as cognitive
impairment), notify the provider if they occur. (p. 96 ATI PHARM)
2. MISSING
3 MISSING
4. A nurse is teaching a client who has a history of acute myocardial infarction about taking metoprolol to treat
angina. Which of the following instructions should the nurse include? Page 158
a. Stop taking the medication if you become dizzy (NEVER discontinue abruptly)
b. Check your pulse rate daily (Bradycardia, withhold if pulse under 50)
c. Expect to see an increase in your urinary output
d. Call you provider if you lose more than 1 pound per week (complication of decreased CO - weight gain - call
provider)
metropolol (Lopressor) - Beta Blockers. Beta1 - affects only the heart. Decreases HR - decreases myocardial
contractility
5. A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration. After assessing
the client’s respiratory status and stopping the medication infusion, which of the following actions should the nurse
take next?
A. Elevate the client’s legs and feet (Raises BP & pulse, maybe just supplementary though)
B. Administer epinephrine IM (Only thing that’ll stop the reaction immed, first line treatment)
C. Replace the solution with with 0.9 % sodium chloride
D. Give diphenhydramine IM
Rationale: If manifestations occur, stop transfusion (ATI’s specific to BLOOD TRANSFUSION, but wouldn’t you still give
epi?), notify provider, and then keep IV line open with NS (in this case, replace the bag with NS?) Then, Have epi ready
for IM or IV injection. Or do you elevate the legs? LOL
6. A nurse is assessing a client who is receiving OXYTOCIN via continuous IV infusion for labor augmentation. The
nurse notes six contractions in a 10 minute period with a nonreassuring FHR. Which of the following actions should
the nurse take first ?
a. Administer Terbutaline 0.25 mg subcutaneously
b. Discontinue the oxycontin IV infusion (INC flow to fetus, control contractions, but not priority)
c. Turn the client on the left side (greatest risk is injury from uteroplacental insufficiency, priority!)
d. Apply oxygen at 10 L / min via face mask
Rationale: Idk. I hate maternity. Someone else rationalize this shit.
Looking through Padgham’s OB notes, reposition goes first apparently. And then I have a note on the bottom, per TB,
O2 first.
7. A nurse is administer lactated ringer's solution at 100ml/hr. The drop factor of the manual IV tubing is 15 gtt/ml.
The nurse should set the manual IV infusion to deliver how many drops per minute? Round the answer to the nearest
whole number? mL / min x gtts
100 x 15/60 = 25 gtt/min
8. A client who has active Tuberculosis and is taking rifampin reports that this urine and sweat have developed a red
orange tinge. Which of the following actions should the nurse take ? page 376
a. Prepare the client for dialysis
b. Instruct the client to increase the fluid intake
c. Check the the clients liver function tests results
d. Document this as an expected finding
Broad Spectrum Antimycobacterial (antituberculosis) - inform clients of expected orange color of urine, sweat,
saliva, and tears.
9. A nurse is teaching a client about self administration of enoxaparin. Which of the following instructions should the
nurse include? (Select all that apply)
a. Grasp the skin between the thumb and forefinger, while injecting the medication - i don’t think
“grasping” and “pinching” is the same thing. But idk. Actually wait….maybe on this sentence they are
b. Alternate the injection sites between the side of the abdomen - rotate and record injection sites
c. Expel the air bubble from the prefilled syringe - do not expel the air from prefilled syringe unless adjustments
must be made with the dose
d. Massage the insertion site after injecting the medication - do not rub the injection site for 1-2 min after
injection
e. Insert the entire length of the needle into the skin during injection - insert needle completely
enoxoparin (Lovenox) - anticoagulant
10. A nurse is caring for a client who is receiving warfarin to treat atrial fibrillation. Which of the following
laboratory lab values should the nurse identify as the outside the expected range for this client?
A. aPTT 36 seconds 35 - 45 seconds
B. Hgb 15.2 g/dl ( 12- 16)
C. Hct 43 % (35- 45)
D. INR 4.5 (2-3 seconds)
PT/INR - for Warfarin; PTT/aPTT - for Heparin
11. A nurse is caring for a client who is receiving ondansetron IV. Which of the following is an indication that the
ondansetron is effective?
a. Increased urinary output
b. Decreased Nausea Antiemetic
c. Absence of peripheral neuropathy
d. Reduced dizziness
Ondansetron - antiemetic: prevents emesis by blocking serotonin receptors; PO, IM, or IV
12. A nurse is caring for a client who has major depression and a new prescription for citalopram. Which of the
following adverse effects should the nurse report to the provider? page 49
SSRI - DEPRESSION
A. Confusion (Serotonin Syndrome)
B. Insomnia
C. Bruxism (Grinding of teeth during sleep, treated with buspirone)
D. Weight Loss (Weight gain)
Serotonin Syndrome
o Agitation, confusion, disorientation, hallucinations, hyperreflexia, tremors, etc
13. A nurses caring for a client who has acute cocaine toxicity. The nurse should plan to provide which of the
following treatments?
⇧HR & BP⇧
a. Gastric Lavage
b. Saline cathartic (laxative)
c. Nalaxone (worsen toxicity, Opioid reversal)
d. Diazepam (Benzodiazepine, Alcohol withdrawal)
I think it’s D for symptoms of agitation and possible seizure due to cocaine toxicity. They can get combative, aggressive,
etc.
14. A nurse is providing teaching to a client who has diabetes insipidus and is receiving DESMOPRESSIN. Which of
the following statements should the nurse include in the teaching ? page 319
a. Your urine might have a reddish tint while taking this medication
b. You will need to check your blood glucose every morning while taking this medication
c. You can expect to have less urine output when you are taking this medication
d. You will need weekly laboratory work to determine your blood clotting time
Antidiuretic hormone - agent of choice for DI.
15. A nurse is teaching a client who has pernicious anemia to self administer nasal cyanocobalamin.Which of the
following information should the nurse include in the teaching?
a. Plan to self administer this medication for the next 6 months (Pernicious Anemia - FO LYF)
b. Administer the medication into one nostril once per week
c. Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose - inform provider - might
decide to delay tx
d. Lie down for 1 hour after administering the medication (administer 1hr before/after hot foods or liquids)
Vitamin B12 - cyanocobalamin
16. A nurse is planning to teach a client who has gout about allopurinol. Which of the following instructions should
the nurse include in the teaching ?
a. Take after meals - minimize GI stress
b. Take an iron supplement
c. Limit fluid intake to 1 liter - increase fluid intake
d. Increase calcium intake - increase incidence of renal calculi with higher excretion of uric acid.
Allopurinol - for hyperuricemia (gout) - used PO or IV
17. A nurse is assessing a client who has heart failure and is taking digoxin. Which of the following findings should the
nurse identify as an early indication of medication toxicity?
a. Visual disturbances - (toxicity: fatigue, weakness, vision changes, GI effects)
b. Insomnia - i don’t think this is relevant. LOL
c. Potassium 4.4 mEq/L - within normal limits
d. Sudden weight gain - GI effects (anorexia, N/V, abd pain)
18.) A nurse is reviewing the medical record of a client who is taking clozapine. Which of the following findings
should the nurse report to the provider immediately?
a. LDL 220 mg/dL (Less than 200)
b. WBC 2,500/mm3 - agranulocytosis is the AE of clozapine (4,500 - 11,000)
c. Fasting blood glucose 180 mg/dL
d. BMI of 28 (Overweight: 25 - 29.9)
Antipsychotic- 2nd gen
19.) A nurse is reviewing the medications of a client. The nurse should recognize that which of the following
medications increases the client’s risk for constipation?
a. Hydromorphone - opioid
b. Neomycin sulfate - antibiotic
c. Prednisone - glucocorticoid
d. Lactulose - laxative
20.) A nurse is caring for a client who is receiving IV amphotericin B. Which of the following findings should the
nurse identify as an acute infusion reaction?
a. Dry cough
b. Fever - infusion reaction: fever, chills, rigor
c. Pedal edema
d. Hyperglycemia
21. A nurse is providing teaching to a client who has a new prescription for bumetanide for heart failure. Which of
the following instructions should the nurse include in the teaching?
a. You should monitor for hearing difficulties - ototoxicity is an AE of bumetanide/loop diuretic
b. You should take this medication on an empty stomach - may cause GI stress
c. You should take the medication at bedtime - avoid administering late in the day or at night to prevent
nocturia
d. You should decrease your intake of foods high in potassium -INC intake of potassium to prevent hypokalemia
22. A nurse is evaluating a client's response to a new prescription for phenazopyridine. Which of the following
outcomes of the medication should the nurse expect?
a . decrease manifestations of GERD
B. improve movement of joints
C. increase ability to cough up secretions
D. relieved burning upon urination - phenazopyridine is a urinary tract analgesic
23. A nurse is caring for a client who has diabetes mellitus and is taking pioglitazone. The nurse should plan to
monitor the client for which of the following adverse effects.
Type 2 Diabetes
a. Insomnia
b. Tinnitus
c. Orthostatic hypotension
d. Fluid retention - AE: fluid retention, elevated LDLs, hepatotoxicity
24. A nurse is caring for a client who has a new prescription for tetracycline. Which of the following statements by the
client indicates an understanding of the teaching.
a. I will avoid drinking milk when i take this medication - reduces absorption
b. I should take an iron supplement with this medication - tetra may stain teeth, so will iron. Idk (DEC
effectiveness!)
c. I won’t worry if i experience diarrhea while taking this medication - may be suprainfection, notify MD
d. I will discontinue this medication when my symptoms go away. - complete entire course of therapy even after
sx go away
25. A nurse is preparing to administer phenytoin suspension 2.5mg/kg PO twice a day to a toddler. The toddler
weighs 22 LB. How many mg should the nurse administer. Round to nearest whole number
22 lb = 10 kg
2.5 mg x 10 kg = 25 mg
26. A nurse is reviewing the medication administration record of a client who received propranolol from a nurse on
the previous shift. The nurse notes the client has an apical heart rate of 50/min prior to administration of the
medication. Which of the following actions should the nurse take?
a. Notify the ethics committee
b. Notify the pharmacy
c. Call the nurse to return to the facility
d. File an incident report
27. A nurse is caring for a client who has acute heart failure and is receiving furosemide via IV bolus. The nurse
should identify that which of the following findings indicates a desired therapeutic effects.
a. Decreased weight - due to excessive diuresis
b. Decreased blood glucose level - HYPERglycemia
c. Increased blood pressure - HYPOtension
d. Increase sputum production
28. A charge nurse is supervising nursing care for four clients. The nurse should recognize that which of the following
situations requires an incident report?
a. A client receives an acetaminophen suppository in place of an oral prescription - med error
b. A nurse administers an antibiotic to a client 30 min after it is due - it is generally acceptable to administer
medications 30 min before or after it is due
c. A nurse administers albuterol to a client who has a heart rate of 55 - albuterol will inc heart rate
d. A client vomits after receiving an oral medication - should be documented on MAR not incident report
29. A nurse is caring for a client who has peptic ulcer disease and is to start antacid therapy. Which of the
following information should the nurse give the client?
a. Take antacids to help inactivate Helicobacter pylori
b. Take chewable tablets rather than suspensions (More effective in liquid)
c. Take antacids within 30 min of the other medication
d. Take antacids 1 hour after meals, 3 hours after meals, and at bedtime
30. A nurse is teaching a client who has prescription for ferrous gluconate. Which of the following statements by the
clients indicates an understanding of the teaching
a. I should stay upright for at least 15 minutes after medication
b. I should notify the provider if my stools turn black (Harmless dark green/black stool)
c. I should take this medication with 8 ounces of milk (DEC absorption)
d. I should take an antacid with this medication to prevent stomach upset (Acid INC absorption)
31. A nurse is providing teaching to a client who is to receive a series of allergy tests. The nurse should instruct the
client to avoid which of the following medications for up to 4 weeks before the procedure?
a. Diphenhydramine (Benadryl) - antihistamine
b. Albuterol
c. Acetaminophen
d. Pseudoephedrine hydrochloride
32. A nurse is caring for a client who has cancer and is undergoing chemotherapy. The client is receiving filgrastim
before each chemotherapy dose. The nurse should monitor for an increase in which of the following types of cells to
determine the effectiveness of the medication?
a. Thrombocytes
b. Erythrocytes
c. Reticulocytes
d. Granulocytes
33. Missing
34. A nurse is assessing a client who takes levothyroxine for ⇩⇩hypothyroidism.⇩⇩ The nurse should identify that
which of the following findings indicates the need for an increase in dosage? SELECT ALL THAT APPLY.
a. Impaired short term memory
b. BP 178/80
c. Cold intolerance
d. Heart rate 46
e. Diaphoresis
35. A nurse recently administered filgrastim intravenously to a client who has cancer and is receiving cytotoxic
chemotherapy. For which of the following data, discovered after the medication was administered, should the nurse
file an incident report?
a. The client's absolute neutrophil count was 2500/mm3 before the medication was administered (1,500 to
8,000)
b. The client has chemotherapy 12 hr before the medication was administered (No earlier than 24 hours
of chemotherapy!)
c. The nurse flushed the client's IV line was dextrose 5% in water before and after the medication was
administered
d. The medication vial sat at room temperature for 2 hr before it was administered (May leave up to 24 hours in
room temp, Don’t freeze or leave in direct sunlight)
Leukopoietic growth factors - stimulates the bone marrow to increase production of neutrophils (range: 1.5-8)
36. A nurse is caring for a client who has heart failure and is taking digoxin and hydrochlorothiazide. The nurse
should monitor for which of the following following adverse effects of hydrochlorothiazide?
a. Hypernatremia
b. Hypophosphatemia
c. Hypermagnesemia
d. Hypokalemia
37. A nurse is assessing a client who is receiving morphine for pain control. Which of the following findings should
the nurse report to the provider.
a. Drowsiness
b. Bladder distension
c. BP 100/76
d. Pupillary constriction OPIOiD OD TRIAD - resp depression, & pinpoint pupils
38. A nurse is teaching a client who has angina about a new prescription for sublingual nitroglycerin tablets. Which
of the following instructions should the nurse include in the teaching?
a. Take one tablet each morning 30 min prior to eating - only for acute pain
b. Keep the tablets at room temperature in their original glass bottle - away from direct heat, moisture, &
light
c. Place the tablet between your cheek and gum to dissolve - under the tongue
d. Discard any tablets you do not use every 6 months (3 months)
39. A nurse is caring for a client who is taking triamterene. For which of the following lab values should the nurse
withhold the medication? K-SPARING!!
a. Sodium 142
b. BUN 16
c. Potassium 5.3
d. Albumin 4 (3.5-5.5)
40.) A nurse is caring for a client who is taking broad spectrum antibiotics for pneumonia. The nurse should identif [Show Less]