NCLEX-RN Nursing — All Questions

A client is prescribed warfarin. Which laboratory value is used to monitor its therapeutic effect?

• a.Prothrombin time and international normalized ratio (INR)✓
• b.Serum potassium and magnesium levels drawn before each dose
• c.Activated partial thromboplastin time (aPTT) drawn each morning
• d.Platelet count alone, repeated at weekly intervals during therapy

Warfarin is monitored using the prothrombin time and INR. The aPTT is used to monitor heparin, not warfarin.

A client receiving IV heparin has an aPTT far above the therapeutic range and is bleeding. Which medication is the antidote?

• a.Calcium gluconate
• b.Vitamin K injection
• c.Protamine sulfate✓
• d.Naloxone hydrochloride

Protamine sulfate reverses heparin. Vitamin K reverses warfarin, and naloxone reverses opioids.

A nurse is administering digoxin. Which finding requires the nurse to hold the dose and notify the provider?

• a.Temperature of 98.6 F (37 C)
• b.Respiratory rate of 16 breaths per minute
• c.Blood pressure of 118/72 mm Hg
• d.Apical heart rate of 52 beats per minute✓

Digoxin should be held for an apical heart rate below 60 beats per minute in adults because it can further slow the heart and may signal toxicity. The other vital signs are within normal limits.

A client is starting an angiotensin-converting enzyme (ACE) inhibitor. Which side effect should the nurse teach the client to report?

• a.Darkened urine that clears quickly
• b.Improved appetite
• c.Increased salivation
• d.A persistent dry cough✓

ACE inhibitors commonly cause a persistent dry cough due to bradykinin accumulation. Clients should report it, and angioedema, though rare, is an emergency.

A nurse prepares to administer an aminoglycoside antibiotic. Which parameters are most important to monitor?

• a.Renal function and drug peak and trough levels✓
• b.Serum calcium and serum phosphate levels each morning
• c.Thyroid hormone levels and the basal metabolic rate
• d.Blood glucose and hemoglobin A1c measured before each dose

Aminoglycosides are nephrotoxic and ototoxic, so renal function and peak and trough serum levels must be monitored to ensure safety and efficacy.

A client is prescribed 250 mg of a medication. The pharmacy supplies 125 mg tablets. How many tablets should the nurse administer?

• a.Four tablets
• b.Half a tablet
• c.One tablet
• d.Two tablets✓

Using desired over available, 250 mg divided by 125 mg per tablet equals two tablets. Accurate dose calculation prevents a medication error.

A nurse teaches a client taking an oral corticosteroid long term. Which instruction is correct?

• a.Take the medication on an empty stomach for best absorption
• b.Avoid monitoring blood glucose, since steroids do not affect it
• c.Do not stop the medication suddenly; taper as directed✓
• d.Stop the medication abruptly once symptoms improve

Long-term corticosteroids must be tapered to avoid adrenal insufficiency. They should be taken with food, and blood glucose should be monitored because they raise glucose.

A client is receiving IV furosemide. Which electrolyte imbalance should the nurse monitor for?

• a.Hypernatremia
• b.Hypercalcemia
• c.Hyperkalemia
• d.Hypokalemia✓

Loop diuretics such as furosemide promote potassium excretion and can cause hypokalemia. The nurse monitors potassium and watches for muscle weakness and cardiac dysrhythmias.

A client taking a monoamine oxidase inhibitor (MAOI) for depression requires dietary teaching. Which food should be avoided?

• a.Freshly steamed carrots
• b.Plain steamed white rice
• c.Fresh apples and pears
• d.Aged cheese and cured meats✓

Tyramine-rich foods such as aged cheese and cured meats can trigger a hypertensive crisis in clients taking MAOIs and must be avoided.

A nurse administers insulin lispro, a rapid-acting insulin. When should the nurse ensure the client is ready to eat?

• a.Meal timing does not matter with lispro
• b.About two hours after the injection
• c.Within about 15 minutes of the injection✓
• d.Only at bedtime with a light snack

Rapid-acting insulin such as lispro begins working within about 15 minutes, so food should be available promptly to prevent hypoglycemia.

A client is prescribed morphine for pain. Which assessment is most important before and after administration?

• a.Deep tendon reflexes and hand grip strength
• b.Skin turgor and oral mucous membrane color
• c.Respiratory rate and level of sedation✓
• d.Bowel sounds in all four quadrants

Opioids such as morphine can cause respiratory depression and sedation, so respiratory rate and sedation level must be assessed before and after administration.

A client taking phenytoin for seizures needs teaching. Which instruction is appropriate?

• a.Stop the drug if a rash appears without contacting the provider
• b.Expect the urine to turn blue
• c.Maintain good oral hygiene because of gum overgrowth risk✓
• d.Skip doses if you feel well

Phenytoin commonly causes gingival hyperplasia, so meticulous oral hygiene is important. Doses should not be skipped, and any rash should be reported because it may signal a serious reaction.

A nurse is administering a beta-blocker such as metoprolol. Which parameter should be checked before administration?

• a.Urine specific gravity and color
• b.Serum bilirubin and albumin levels
• c.Total white blood cell count
• d.Apical heart rate and blood pressure✓

Beta-blockers lower heart rate and blood pressure, so both should be assessed before administration and the dose held for significant bradycardia or hypotension per parameters.

A client on lithium for bipolar disorder reports vomiting, coarse tremors, and confusion. What does the nurse suspect?

• a.Normal side effects that require no action
• b.A therapeutic drug response
• c.A common cold
• d.Lithium toxicity✓

Vomiting, coarse tremors, and confusion are signs of lithium toxicity. The narrow therapeutic range makes level monitoring and adequate hydration essential.

A client is prescribed an oral tetracycline antibiotic. Which instruction is correct?

• a.Take it with milk or antacids to reduce stomach upset
• b.Take each dose only with grapefruit juice for absorption
• c.Double the next dose whenever a dose is missed to catch up
• d.Avoid dairy products and antacids near the time of the dose✓

Calcium in dairy and antacids binds tetracycline and reduces its absorption, so they should be separated from the dose. Doses should not be doubled if missed.

A nurse is preparing to administer a medication and notes the client has a documented allergy to it. What is the nurse's action?

• a.Hold the medication and notify the prescriber✓
• b.Give a smaller dose to test tolerance
• c.Give the medication and monitor closely
• d.Administer with an antihistamine to prevent a reaction

A documented allergy is a contraindication. The nurse holds the drug and notifies the prescriber to clarify or change the order, preventing a potentially life-threatening reaction.

A client is receiving an IV infusion of potassium chloride. Which action is essential for safety?

• a.Stop cardiac monitoring during the infusion to reduce alarms
• b.Administer the potassium by rapid IV push to correct the level
• c.Infuse diluted potassium slowly using an infusion pump✓
• d.Give the potassium undiluted so that it takes effect faster

IV potassium must always be diluted and infused slowly with a pump; it is never given by IV push because rapid administration can cause fatal cardiac arrest. Cardiac monitoring is important.

A client taking an opioid reports no bowel movement for three days. Which intervention should the nurse anticipate?

• a.Initiating a bowel regimen with a stool softener and increased fluids✓
• b.Discontinuing the opioid without consulting the provider who prescribed it
• c.Withholding oral fluids until the client passes a bowel movement alone
• d.Restricting all dietary fiber to rest the bowel until stooling returns

Opioids commonly cause constipation, so a prophylactic bowel regimen with stool softeners, fluids, and fiber is appropriate. Fluids and fiber should be increased, not restricted.

A prescription reads: 'Give 1.5 g of an oral medication by mouth twice daily.' The pharmacy supplies scored 500 mg tablets. How many tablets should the nurse give for one dose?

• a.Administer 6 tablets
• b.Administer 1.5 tablets
• c.Administer 3 tablets✓
• d.Administer 0.3 tablet

Convert before dividing: 1.5 g = 1,500 mg, and 1,500 mg / 500 mg per tablet = 3 tablets per dose; checked a second way, each tablet is 0.5 g and 1.5 g / 0.5 g = 3. The most tempting wrong answer is 1.5 tablets, which comes from dividing as though each tablet held 1 g instead of converting grams to milligrams first; 6 tablets is the whole 24-hour amount given at once, and 0.3 tablet is the inverted ratio (500 / 1,500 = 0.33) rounded to a tenth. Tablets are counted in whole or half units here, so no decimal rounding is involved.

A prescription reads: 'Give 40 mg of a medication intramuscularly now.' The vial is labeled 100 mg per 2 mL. How many milliliters should the nurse draw up?

• a.Administer 0.4 mL
• b.Administer 5 mL
• c.Administer 2 mL
• d.Administer 0.8 mL✓

The vial holds 100 mg / 2 mL = 50 mg per mL, so 40 mg / 50 mg per mL = 0.8 mL; worked a second way, 40 mg x 2 mL / 100 mg = 0.8 mL. The tempting error is 0.4 mL, produced by dividing 40 by 100 and forgetting to multiply by the 2 mL the drug is dissolved in; 2 mL is the whole vial and 5 mL is the ratio inverted (100 / 40 x 2). Doses below 1 mL are written with a leading zero as 0.8 mL, because .8 mL can be read as 8 mL if the decimal point is missed.

A child weighs 44 lb. The prescriber orders an oral antibiotic at 30 mg/kg/day, to be given in equally divided doses every 8 hours. How many milligrams should the nurse give per dose?

• a.440 mg per dose
• b.600 mg per dose
• c.200 mg per dose✓
• d.300 mg per dose

44 lb / 2.2 lb per kg = 20 kg; 20 kg x 30 mg/kg/day = 600 mg for the day; every 8 hours is 3 doses, so 600 mg / 3 = 200 mg per dose (rechecked: 30 x 20 = 600, 600 / 3 = 200). The 440 mg answer is what you get by treating the 44 lb as 44 kg, the exact confusion that led ISMP and NCC MERP to recommend that weights be measured and documented in kilograms only. The 600 mg answer gives the full day at once and 300 mg divides the day into two doses instead of three.

A child weighs 33 lb. The safe range for the prescribed medication is 10 to 15 mg/kg per dose. The prescriber writes an order for 250 mg per dose. What should the nurse do?

• a.Withhold the dose and contact the prescriber to have the amount reduced✓
• b.Give the dose as written, since it is within the range for this child's weight
• c.Give the dose as written and monitor the child closely for toxic effects
• d.Give 225 mg now and ask the prescriber to rewrite the order afterward

33 lb / 2.2 = 15 kg, so this child's safe range is 15 x 10 = 150 mg to 15 x 15 = 225 mg per dose, and the ordered 250 mg is above the maximum, so the nurse holds it and contacts the prescriber. Trimming the amount to 225 mg is the most tempting wrong action because the number is right: changing a dose is prescribing rather than administering, and the nurse who silently corrects an order leaves no record for the next clinician. Giving an unsafe dose and watching for toxicity treats harm as acceptable when it was preventable.

A prescriber orders 250 mL of 0.9% sodium chloride to infuse over 90 minutes. The volumetric pump accepts whole milliliters per hour. What rate should the nurse set?

• a.Set the pump at 125 mL/hr
• b.Set the pump at 375 mL/hr
• c.Set the pump at 250 mL/hr
• d.Set the pump at 167 mL/hr✓

250 mL / 90 min x 60 min per hr = 166.7, which the nurse rounds to 167 mL/hr because this pump takes whole numbers; checked a second way, 90 minutes is 1.5 hours and 250 / 1.5 = 166.7. The 125 mL/hr answer comes from rounding 90 minutes up to 2 hours, 250 mL/hr from treating 90 minutes as an hour, and 375 mL/hr from multiplying by 1.5 instead of dividing by it.

A client is to receive 1,000 mL of lactated Ringer's over 10 hours by gravity. The tubing package states a drop factor of 15 gtt/mL. How many drops per minute should the nurse count?

• a.Regulate the flow at 33 gtt/min
• b.Regulate the flow at 100 gtt/min
• c.Regulate the flow at 25 gtt/min✓
• d.Regulate the flow at 17 gtt/min

1,000 mL x 15 gtt/mL = 15,000 drops over 600 minutes = 25 gtt/min; checked a second way, 1,000 mL / 10 hr = 100 mL/hr = 1.67 mL/min, and 1.67 x 15 = 25 gtt/min. Each wrong answer is the same problem worked with the wrong drop factor, which is why the factor is read off the tubing package every time: a 10 gtt/mL set gives 17, a 20 gtt/mL set gives 33, and a 60 gtt/mL microdrip set gives 100. A fraction of a drop cannot be delivered, so drip rates are rounded to the nearest whole drop.

A continuous infusion of aqueous penicillin G 4,000,000 units in 250 mL of dextrose 5% in water is running by pump at 50 mL/hr. How many units is the client receiving each hour?

• a.800,000 units/hr✓
• b.4,000,000 units/hr
• c.16,000 units/hr
• d.20,000,000 units/hr

The bag holds 4,000,000 units / 250 mL = 16,000 units per mL, and at 50 mL/hr that is 16,000 x 50 = 800,000 units/hr; checked a second way, 50 mL is one fifth of the 250 mL bag, and one fifth of 4,000,000 is 800,000. Reporting 16,000 units/hr stops at the concentration and never multiplies by the rate, which is the most common slip here; 4,000,000 units/hr assumes the whole bag runs in one hour, and 20,000,000 units/hr comes from inverting the rate and the volume (250 / 50 rather than 50 / 250).

A vial of powdered antibiotic reads: 'Add 8.6 mL of sterile water for injection to yield 1 g per 10 mL.' The order is for 600 mg IV. After reconstituting the vial, how much should the nurse withdraw?

• a.Withdraw 5.2 mL
• b.Withdraw 8.6 mL
• c.Withdraw 6 mL✓
• d.Withdraw 0.6 mL

The reconstituted vial holds 1 g (1,000 mg) in 10 mL, which is 100 mg per mL, so 600 mg / 100 mg per mL = 6 mL; checked a second way, 600 mg is 0.6 of a gram and 0.6 x 10 mL = 6 mL. The most tempting error is 8.6 mL, the volume of diluent added rather than the volume of the dose: the powder itself occupies space, so the final volume of 10 mL is larger than the 8.6 mL of water and the dose is always calculated from the final volume printed on the label. Using 8.6 mL as the final volume yields 5.2 mL, and dropping the 10 mL entirely yields 0.6 mL.

An infant weighs 9.5 kg. The prescriber orders an oral suspension at 20 mg/kg per dose. The bottle is labeled 250 mg per 5 mL. How many milliliters should the nurse give, rounded to the nearest tenth?

• a.Administer 3.8 mL✓
• b.Administer 19 mL
• c.Administer 6.6 mL
• d.Administer 0.76 mL

9.5 kg x 20 mg/kg = 190 mg per dose; the suspension is 250 mg / 5 mL = 50 mg per mL, so 190 mg / 50 mg per mL = 3.8 mL, and checked a second way 190 x 5 / 250 = 3.8 mL. Oral liquid volumes above 1 mL are rounded to the tenth, so 3.8 mL is what the nurse draws into an oral syringe. The 0.76 mL answer divides 190 by 250 and never multiplies by the 5 mL, 19 mL applies the 5 mL a second time after already converting to 50 mg per mL, and 6.6 mL inverts the ratio (250 / 190 x 5).

A nurse is about to give a scheduled oral medication on a busy medical unit. Which method of identifying the client meets the National Patient Safety Goal for medication administration?

• a.Ask the client to state their name and date of birth✓
• b.Ask the client to confirm the name on the medication record
• c.Check the room and bed number listed on the medication record
• d.Confirm the name with the nursing assistant assigned to the room

NPSG.01.01.01 requires at least two person-specific identifiers, such as the name plus an assigned number or date of birth, and states explicitly that the client's room number or physical location is not used as an identifier. Asking the client to confirm a name read aloud is a single identifier and invites a drowsy, anxious, or hard-of-hearing client to agree to the wrong one; having the client state the information and matching it against the record is what catches a wrong-client error.

A 70-year-old client with osteoporosis is discharged with a new prescription for oral alendronate once weekly. Which statement by the client indicates that teaching about how to take the tablet was effective?

• a.I'll swallow it with coffee when the breakfast tray comes and sit up.
• b.I'll take it with plain water on waking and stay upright 30 minutes.✓
• c.I'll swallow it with plain water at bedtime and lie down to sleep.
• d.I'll swallow it with plain water and my calcium tablet together.

Alendronate labelling directs that the tablet be taken on arising for the day, at least 30 minutes before the first food, drink or other medication, swallowed whole with a full glass (180 to 240 mL) of plain water, and that the client not lie down for at least 30 minutes and until after the first food of the day; a tablet that lingers in the esophagus can cause ulceration. The morning empty-stomach timing is what makes the upright interval work, so a correct answer has to carry both halves. Taking it at the same time as a calcium tablet is the most tempting error, since calcium and other multivalent cations bind the drug in the gut and block its absorption; calcium, antacids and other oral medications must be separated from the dose by at least 30 minutes.

A client is admitted to a medical unit. Which action by the nurse best meets the medication reconciliation requirement?

• a.Order every medication the client names at home to be continued during this stay
• b.Compare the medications the client takes at home with the admission orders✓
• c.File the pharmacy refill history for the prescriber to review later
• d.Copy the medication list from the client's most recent hospital discharge summary

NPSG.03.06.01 asks the nurse to obtain the medications the client is currently taking, including as-needed and over-the-counter products, and then compare that information with what has been ordered so that omissions, duplications, and interactions are identified and resolved. An earlier discharge summary is not the current list, and copying it forward carries the last admission's errors into this one; a refill history filed for later review completes no comparison at all.

A nurse withdraws and gives the ordered 4 mg from a single-dose vial containing 10 mg of a Schedule II analgesic. What should the nurse do with the medication left in the vial?

• a.Return the vial to the automated dispensing cabinet for the client's next dose
• b.Place the vial in the sharps container and document the amount that was given
• c.Waste it into the pharmaceutical waste container with a second nurse witnessing and cosigning✓
• d.Empty it into the sink at the end of the shift and record it on the count sheet

ISMP's guidance is to draw the remaining medication out of the vial with a witness present, have the witness verify the volume, empty it into a pharmaceutical waste container while the witness watches, and document the amount with the witness's cosignature. Dropping the vial into the sharps container is the common shortcut and is unsafe, because the drug is still recoverable from the vial and no one has verified what was actually wasted. Waste is done at the time of administration, not saved for the end of the shift.

A client is discharged with fentanyl transdermal patches. Which statement by the client indicates that teaching about handling the patches was effective?

• a.'I'll leave the old patch on for a few hours after the new one goes on to avoid a gap.'
• b.'I'll put the used patch back in its pouch and drop it in the kitchen trash can.'
• c.'If the patch stops helping, I'll lay a heating pad over it to move the medicine along.'
• d.'When I take a patch off, I'll fold it so the sticky sides stick together and flush it.'✓

The fentanyl transdermal system labeling tells users to fold the used system so the adhesive side sticks to itself and flush it down the toilet immediately after removal, and FDA keeps fentanyl on its flush list precisely because a used patch holds enough drug to kill a child or pet who finds it in the trash. Heat is the most dangerous misconception here: the label warns against heating pads, electric blankets, saunas, and hot tubs over the site because external heat increases absorption and can cause overdose, and the previous patch is removed before a new one goes on a different site.

A nurse checks a peripheral IV infusing 0.9% sodium chloride into a client's forearm. The site is swollen and pale, the skin is cool and taut, and the pump keeps alarming. What should the nurse do first?

• a.Stop the infusion and remove the catheter, then elevate the arm✓
• b.Flush the catheter with saline to see whether the line clears
• c.Notify the provider and continue the infusion until orders arrive
• d.Apply a warm compress and slow the infusion to a keep-open rate

Swelling with cool, taut, pale skin and a sluggish or alarming infusion is infiltration, a non-vesicant solution leaking into the tissue around the vein, and the first action is to stop the infusion and remove the catheter so no more fluid enters the tissue. Flushing is the tempting wrong move because it looks like troubleshooting an occlusion: it forces more fluid into the tissue, and no flush can restore a catheter whose tip is out of the vein. Escalation is not the first step when the nurse can stop the harm immediately.

A client returns to the clinic six weeks after starting atorvastatin for hyperlipidemia. Which report by the client requires the nurse to notify the provider?

• a.Loose stools on two mornings that settled after breakfast
• b.Heartburn on several evenings after a large late meal
• c.Trouble falling asleep on nights after drinking coffee
• d.Aching and weakness in both thighs over the past week✓

Unexplained aching and weakness in the large proximal muscles is how statin-associated myopathy presents, and it can progress to rhabdomyolysis, so the atorvastatin labelling directs clients to report unexplained muscle pain, tenderness, or weakness promptly; the provider can then check a creatine kinase level and decide whether to stop the drug. Loose stools are the most tempting of the other reports because diarrhea really is a statin effect, but diarrhea, dyspepsia, and insomnia sit among the common adverse reactions in the labelling and are handled with reassurance rather than a call.

A nurse is preparing to give an IV push medication through the needleless connector of a client's central venous catheter. What should the nurse do immediately before attaching the syringe?

• a.Take down the dressing to inspect the insertion site
• b.Scrub the connector with an antiseptic and let it dry✓
• c.Replace the needleless connector before each medication
• d.Wipe the connector with sterile gauze moistened with saline

CDC's intravascular catheter guideline directs the nurse to perform hand hygiene before accessing a catheter and to scrub the access port with an appropriate antiseptic such as chlorhexidine, an iodophor, or 70% alcohol, accessing the port only with sterile devices; the connector must then be allowed to dry, because an antiseptic that is still wet has not finished working. Saline is not an antiseptic, and neither swapping an intact connector nor taking down an intact dressing is part of accessing the line for a dose.

An IV nitroglycerin infusion is ordered for chest pain: start at 5 mcg/min, increase by 5 mcg/min every 5 minutes until the pain is relieved, maximum 40 mcg/min, and hold for a systolic blood pressure below 100 mm Hg. The infusion is at 20 mcg/min, the client still rates the pain 6 out of 10, and the systolic pressure is now 94 mm Hg. What should the nurse do?

• a.Increase the rate to 25 mcg/min, because the chest pain has not yet been relieved
• b.Keep the rate at 20 mcg/min and recheck the blood pressure at the end of the shift
• c.Increase the rate to the 40 mcg/min maximum to relieve the chest pain sooner
• d.Hold the next increase and notify the provider, since the systolic pressure is below 100 mm Hg✓

A titration order contains both a target to treat toward and a safety parameter that stops the titration, and a parameter that has been crossed outranks a target that has not yet been reached, so the nurse does not give the next increment at a systolic pressure of 94 mm Hg. The tempting error is to keep titrating because the pain is unrelieved; nitroglycerin can produce severe hypotension at even small doses, and driving the pressure lower reduces coronary perfusion rather than improving it. Because the pain persists at a dose that can no longer be raised, this is a situation where the provider genuinely does need to be called.

A nurse teaches an older adult to instill two different prescribed eye drops into the same eye. Which statement indicates that the teaching was effective?

• a.'I'll rest the bottle tip on my lashes so the drop lands in one place.'
• b.'I'll drop it right onto the middle of my eye so it spreads over the surface.'
• c.'I'll put in the second drop right after the first one so I do not forget it.'
• d.'I'll put the drop in the pocket of my lower lid and press the inner corner.'✓

The drop belongs in the pocket formed by pulling down the lower lid rather than on the cornea, and closing the eye and pressing gently over the tear duct at the inner corner keeps the drug in the eye instead of draining it into the nose and bloodstream. Instilling the second drop immediately is the most tempting error because it feels efficient: it washes the first drug out, and MedlinePlus instructs waiting at least 5 minutes between drops in the same eye. Touching the bottle tip to lashes or lid contaminates the dropper.

A nurse must give three oral medications through a client's gastrostomy tube during a continuous tube feeding. Which action is correct?

• a.Give the three medications one after another without flushing between
• b.Add the three medications to the enteral formula bag before hanging it
• c.Give each medication separately, flushing with water between them✓
• d.Mix the three medications and give them in one syringe

ISMP and ASPEN direct the nurse to stop the feeding, flush the tube with water before, between, and after each medication, and prepare and give each medication separately, because combining drugs in one syringe creates a mixture whose compatibility no one has established and is a leading cause of tube occlusion. Adding medications to the formula bag is specifically warned against, since drug-nutrient interactions and blockage follow.

A nurse is giving an intramuscular vaccine in the deltoid to an adult woman who weighs 230 lb (104 kg). Which needle should the nurse select?

• a.A 22- to 25-gauge needle, 1.5 inches long✓
• b.A 20- to 22-gauge needle, 2 inches long
• c.A 23- to 25-gauge needle, 5/8 inch long
• d.A 22- to 25-gauge needle, 1 inch long

CDC's needle-length table specifies a 22- to 25-gauge, 1.5-inch (38 mm) needle for an intramuscular deltoid injection in a woman weighing more than 200 lb, because the needle has to pass through subcutaneous fat and reach muscle. The 1-inch needle is the length listed for adults up to about 152 lb and is the most tempting choice, but at this weight it risks depositing the vaccine subcutaneously, where absorption and the immune response are poorer and local reactions are more common; the 5/8-inch, 23- to 25-gauge needle is the subcutaneous specification.

A nurse is giving a deep intramuscular injection of a dark, staining medication whose label directs that it be given by Z-track. Which action is part of this technique?

• a.Press the skin down over the site and apply a pressure dressing afterward
• b.Displace the skin and tissue laterally, hold it during the injection, then release✓
• c.Pinch the skin and tissue upward and release it just before the needle comes out
• d.Stretch the skin taut over the site and massage the area firmly afterward

The iron dextran labeling describes Z-track as displacement of the skin laterally before injection, and the tissue is held displaced until after the needle is withdrawn so the layers slide back over one another and seal the needle track, which keeps a staining or irritating drug from leaking up into subcutaneous tissue. Pinching tissue upward is the subcutaneous technique, and massaging the site afterward is the most tempting wrong step because it is routine for some injections: here it pushes drug back along the track that the technique was meant to close.

A client with COPD received a scheduled dose of an inhaled short-acting bronchodilator 15 minutes ago. Which finding best indicates the intended response?

• a.The client's oral temperature has fallen from 38.1 C to 37.2 C since the dose
• b.The client reports that the mouth feels less dry than it did before the dose
• c.The client's heart rate has risen from 78 to 96 beats per minute since the dose
• d.The client speaks a full sentence without pausing, and wheezing has decreased✓

A short-acting bronchodilator is given to open the airways, so the evidence that it worked is an airway finding: less wheezing and enough breath to finish a sentence. The rise in heart rate is the most tempting distractor because it is a real, measurable change caused by the drug, but tachycardia is a beta-adrenergic side effect rather than the therapeutic goal, and temperature and mouth dryness measure outcomes the drug was not given to change.

A nurse is orienting a newly hired nurse to the administration of intravenous potassium chloride from a concentrate vial. Which statement by the newly hired nurse indicates correct understanding?

• a.I will give it only as a diluted infusion controlled by a pump.✓
• b.I will push the concentrate slowly over five minutes into a large vein.
• c.I will infuse it undiluted through a central line to protect the veins.
• d.I will regulate the diluted infusion by gravity and count the drip rate.

Potassium chloride concentrate must be diluted before use and infused at a controlled rate, because direct injection of the concentrate may be instantaneously fatal. Giving the concentrate by push or infusing it undiluted through a central line both deliver an undiluted bolus, and gravity tubing cannot guarantee the rate limit.

A client is prescribed 8 units of NPH human insulin and 4 units of regular human insulin, to be mixed in one syringe and given subcutaneously. Which action should the nurse take?

• a.Draw the NPH insulin into the syringe before the regular insulin.
• b.Draw the NPH insulin first and roll the filled syringe between the palms.
• c.Draw the regular insulin first and store the filled syringe for one hour.
• d.Draw the regular insulin into the syringe before the NPH insulin.✓

Both manufacturers' labelling states that when regular human insulin is mixed with NPH, the regular insulin is drawn into the syringe first and the injection is given immediately after mixing. Drawing NPH first risks carrying the cloudy suspension back into the clear regular vial, and holding the mixed syringe for an hour ignores the instruction to inject immediately.

A client's prescriptions include insulin glargine at bedtime and insulin lispro before meals. The bedtime dose is due. Which action should the nurse take?

• a.Add the glargine to the running intravenous fluid at bedtime.
• b.Give the glargine in its own syringe, not mixed with another insulin.✓
• c.Mix the glargine with the lispro dose, drawing the lispro up first.
• d.Dilute the glargine with sterile water before drawing the dose.

Insulin glargine labelling directs that it not be diluted or mixed with any other insulin or solution, and that it not be given intravenously, so it is drawn and injected on its own. The lispro is a separate subcutaneous injection, not a syringe partner.

A client on day 6 of a continuous IV heparin infusion has a platelet count of 68,000/mm3; the count before therapy was 210,000/mm3. Which action should the nurse take?

• a.Continue the infusion and request an order for protamine sulfate.
• b.Hold the infusion and report the platelet count to the provider.✓
• c.Continue the infusion and recheck the platelet count in 24 hours.
• d.Slow the infusion by half and apply a pressure dressing to the site.

Heparin labelling directs that heparin be promptly discontinued and the client evaluated for heparin-induced thrombocytopenia if the platelet count falls below 100,000/mm3, so the nurse holds the drug and reports the value. Continuing or merely slowing the infusion leaves the client exposed to the antibody-mediated thrombosis that makes this reaction dangerous.

A client has an indwelling epidural catheter for postoperative analgesia and is receiving subcutaneous enoxaparin. Which finding requires immediate follow-up?

• a.A 2-cm bruise at the abdominal injection site.
• b.New numbness of both legs with an inability to void.✓
• c.An aPTT that is unchanged from the pretreatment value.
• d.Mild soreness at the epidural insertion site.

The boxed warning for enoxaparin describes spinal or epidural hematoma that can cause long-term or permanent paralysis, and directs frequent monitoring for neurological impairment; new bilateral leg numbness with urinary retention is that emergency. An unchanged aPTT is expected, because labelling states the aPTT is not adequate for monitoring enoxaparin.

A mechanically ventilated client in the intensive care unit is receiving a continuous vecuronium infusion. Which action should the nurse take?

• a.Reserve sedation for the times when the client's heart rate climbs above 100.
• b.Give sedation and analgesia, because vecuronium does not relieve pain.✓
• c.Withhold the ordered sedation, because vecuronium produces unconsciousness.
• d.Stop the infusion each shift to assess the client's pain verbally.

Vecuronium labelling states the drug has no known effect on consciousness, the pain threshold, or cerebration, and that administration must be accompanied by adequate anesthesia or sedation. A paralyzed client cannot report pain, so waiting for a verbal report or for a rise in heart rate leaves the client aware and untreated.

During a peripheral infusion of vincristine, a client reports burning at the IV site, and the nurse finds swelling and no blood return. Which action should the nurse take first?

• a.Stop the infusion, leave the catheter in, and aspirate residual drug.✓
• b.Slow the infusion and raise the arm above the level of the heart.
• c.Remove the catheter and apply firm pressure over the swollen area.
• d.Flush the catheter with 10 mL of 0.9% sodium chloride to clear the vein.

Vincristine is a vesicant; the described protocol is to halt and disconnect the infusion while leaving the needle or cannula in position and gently aspirating the extravasated solution without flushing the line. Flushing pushes more vesicant into the tissue, and pulling the catheter first gives up the access needed to aspirate.

A 76-year-old client takes digoxin and furosemide daily and now reports nausea, poor appetite, and yellow-green halos around lights. In addition to the serum digoxin concentration, which laboratory value should the nurse review?

• a.Serum bilirubin level
• b.Serum albumin level
• c.Serum amylase level
• d.Serum potassium level✓

Digoxin labelling lists hypokalemia, hypercalcemia, and hypomagnesemia as conditions that predispose to digoxin toxicity, and a loop diuretic such as furosemide wastes potassium, so the potassium level is the value that explains toxic symptoms at an ordinary dose. Bilirubin, amylase, and albumin do not change digoxin sensitivity.

A client who takes phenytoin for a seizure disorder has a total serum phenytoin concentration of 27 mcg/mL. Which assessment finding should the nurse expect?

• a.Flushing of the face and neck with itching
• b.Yellow-green halos around bright lights
• c.Nystagmus when the eyes track to the side✓
• d.Coarse hand tremor with repeated vomiting

Phenytoin labelling places the usual therapeutic total concentration at 10 to 20 mcg/mL and states that nystagmus on lateral gaze usually appears at 20 mcg/mL, so a level of 27 mcg/mL should produce it. Yellow-green vision suggests digoxin toxicity, coarse tremor with vomiting suggests lithium toxicity, and upper-body flushing follows a rapid vancomycin infusion.

The pharmacy sends vancomycin 1 g in 250 mL of dextrose 5% in water labelled to infuse over 30 minutes. Which action should the nurse take?

• a.Start the infusion as sent and draw a trough level 30 minutes afterward.
• b.Question the rate, since a dose is infused over at least 60 minutes.✓
• c.Infuse it by gravity and count the drip rate every 15 minutes.
• d.Premedicate with diphenhydramine and infuse the dose over 30 minutes.

Vancomycin labelling directs that each dose be given at no more than 10 mg/min or over a period of at least 60 minutes, because rapid infusion can cause exaggerated hypotension and flushing of the upper body. Premedicating does not make an unsafe rate safe, and a trough drawn immediately after the dose does not address the rate at all.

A client who had a mechanical mitral valve replacement is taking warfarin. Today's INR is 1.6. How should the nurse interpret this result?

• a.Below the target range of 2.5 to 3.5 for a mechanical mitral valve✓
• b.Within the target range of 1.5 to 2.0 for a mechanical mitral valve
• c.Within the target range of 1.6 to 2.5 for a mechanical mitral valve
• d.Above the target range of 1.0 to 1.5 for a mechanical mitral valve

Warfarin labelling sets a target INR of 3.0 with a range of 2.5 to 3.5 for a mechanical mitral valve, so an INR of 1.6 is subtherapeutic and leaves the client at risk for valve thrombosis. The lower ranges offered belong to no labelled warfarin indication; even venous thromboembolism and atrial fibrillation are anticoagulated to 2.0 to 3.0.

A client takes lithium carbonate at 0800 and at 2000. The provider orders a serum lithium level. When should the nurse arrange the blood draw?

• a.Just before the 0800 dose, 8 to 12 hours after the evening dose✓
• b.Just after the 2000 dose, at the end of the dosing day
• c.One hour after the 0800 dose, when absorption is complete
• d.At about 1400, roughly midway between the two scheduled doses

Lithium labelling directs that blood samples be drawn immediately prior to the next dose, 8 to 12 hours after the previous dose, when concentrations are relatively stable. A sample drawn soon after a dose reflects the absorption peak and can look falsely toxic, which may lead to an unnecessary dose reduction.

A client with heart failure takes lisinopril daily and has a new prescription for spironolactone. This morning's serum potassium is 5.9 mEq/L. Which action should the nurse take?

• a.Give both drugs and add an oral potassium supplement at noon.
• b.Hold the spironolactone and report the potassium result.✓
• c.Hold the lisinopril and give the spironolactone as prescribed.
• d.Give the spironolactone and recheck the potassium in 3 days.

Spironolactone is contraindicated in hyperkalemia, and its labelling warns that the risk rises when it is combined with an ACE inhibitor such as lisinopril; a potassium of 5.9 mEq/L is above the upper limit of normal, so the dose is held and reported. Substituting one of the two drugs for the other still adds a potassium-raising agent to an already elevated level.

A client with rheumatoid arthritis is going home on oral methotrexate. Which statement by the client indicates that the teaching about the regimen was effective?

• a.I take one tablet each morning with my breakfast.
• b.I take an extra dose on days my joints ache more.
• c.I have my blood counts checked once a year.
• d.I take the whole dose on one day each week.✓

Methotrexate for rheumatoid arthritis is prescribed once weekly, and the labelling states plainly that mistaken daily use of the recommended dose has led to fatal toxicity, so taking the full amount on a single day of the week shows the teaching took hold. Daily or extra dosing is the dangerous error the warning exists for, and blood counts are followed at least monthly during therapy rather than yearly.

A client with severe preeclampsia is receiving IV magnesium sulfate. The nurse finds the patellar reflex absent, respirations 10 breaths per minute, and urine output 20 mL over the past hour. Which action should the nurse take first?

• a.Stop the magnesium infusion and prepare to give calcium gluconate.✓
• b.Continue the infusion and recheck the patellar reflex in one hour.
• c.Give a 500 mL fluid bolus and recheck the urine output in 2 hours.
• d.Increase the magnesium rate and turn the client onto her left side.

Magnesium sulfate labelling names the presence of the patellar reflex, respirations of about 16 or more per minute, and urine output of 100 mL every 4 hours as indicators of a safe regimen, and directs that an injectable calcium salt be immediately available to counteract magnesium intoxication. Continuing or increasing the infusion while reflexes are gone risks respiratory paralysis.

A client who received naloxone for respiratory depression after a dose of extended-release morphine is now awake with a respiratory rate of 16. Which action should the nurse take?

• a.Restart the morphine infusion at half of the previous rate.
• b.Give the next morphine dose now that the client is awake.
• c.Document the recovery and resume routine shift assessments.
• d.Keep monitoring, since the morphine may outlast the naloxone.✓

Naloxone labelling warns that the duration of action of most opioids may exceed that of naloxone, so respiratory and central nervous system depression can return after an initial improvement and the client needs continued surveillance and possibly repeat doses. Returning to routine assessments or redosing the opioid treats the improvement as permanent.

A postoperative client who received IV midazolam and IV hydromorphone is difficult to arouse with a respiratory rate of 7. Flumazenil is prescribed. Which understanding should guide the nurse's care?

• a.It reverses the hydromorphone and leaves the midazolam fully active.
• b.It reverses both drugs, so no other reversal agent is needed.
• c.It will work only after the hydromorphone has been fully metabolized.
• d.It reverses the midazolam but has no effect on the hydromorphone.✓

Flumazenil labelling states that it reverses the sedative effects of benzodiazepines and does not reverse the effects of opioids, so opioid-related respiratory depression persists and naloxone may still be required. Labelling also directs monitoring for resedation for up to 120 minutes after flumazenil is given.

Fifteen minutes into a transfusion of packed red blood cells, a client has shaking chills, flank pain, dark red urine, and a temperature that has risen from 37.6 C to 39.1 C. Which action should the nurse take first?

• a.Change the infusing solution to lactated Ringer's and continue the unit slowly.
• b.Stop the transfusion and keep the vein open with 0.9% sodium chloride through new tubing.✓
• c.Give the prescribed antipyretic and continue the transfusion at the ordered rate.
• d.Slow the transfusion to 50 mL per hour and recheck the temperature and pulse in 15 minutes.

When a transfusion reaction occurs the transfusion must be discontinued immediately; fresh tubing and 0.9% sodium chloride preserve venous access without delivering any more of the implicated unit, and these findings suggest an acute hemolytic reaction. Lactated Ringer's contains calcium and should not be infused through the same tubing as a citrated blood component.

An 82-year-old client with chronic anemia and heart failure receives 2 units of packed red blood cells over 2 hours. One hour later the client has dyspnea, crackles, jugular venous distention, blood pressure 178/96 mm Hg, and oxygen saturation 87%. Which complication do these findings most suggest?

• a.Transfusion-associated circulatory overload✓
• b.Acute hemolytic transfusion reaction
• c.Febrile nonhemolytic transfusion reaction
• d.Transfusion-related acute lung injury

Circulatory overload follows volumes or rates the heart cannot accommodate and shows hydrostatic pulmonary edema with hypertension and jugular venous distention, and the elderly and clients with chronic anemia or cardiac disease are at particular risk. Transfusion-related acute lung injury also causes hypoxemia within 6 hours but produces noncardiogenic edema with hypotension rather than the volume-overload picture described.

A nurse is 10 minutes into a client's first intravenous dose of a cephalosporin antibiotic. Which finding requires immediate intervention?

• a.A blood pressure of 126/78 and a pulse of 94
• b.Hoarseness and wheezing with swollen lips✓
• c.A small bruise where the catheter was inserted
• d.A dull headache that began before the infusion

Mucosal swelling together with airway findings such as hoarseness and wheezing minutes after a drug exposure meets the clinical criteria for anaphylaxis, so the infusion is stopped and intramuscular epinephrine, 0.3 to 0.5 mL of the 1:1,000 concentration into the mid-outer thigh, is given without delay; antihistamines are adjuncts whose benefit in anaphylaxis is unproven and they do not protect the airway. The other findings are unremarkable vital signs, a local mark at the insertion site, and a symptom that started before the drug was hung.

A client's continuous parenteral nutrition bag empties and the replacement bag is delayed in the pharmacy. For which complication should the nurse assess this client?

• a.Hypernatremia with dry mucous membranes
• b.Hypercalcemia with severe muscle weakness
• c.Hyperkalemia with peaked T waves on the ECG
• d.Hypoglycemia with diaphoresis and tremor✓

Sudden discontinuation of parenteral nutrition can lead to hypoglycemia, because circulating insulin remains high after the concentrated dextrose infusion stops. The nurse checks a capillary glucose, watches for diaphoresis and tremor, and obtains the replacement solution without delay.

A nurse enters the room of a client using an intravenous patient-controlled analgesia pump and finds the client's daughter pressing the demand button while the client sleeps. Which action should the nurse take?

• a.Stop the daughter and teach that only the client presses the button.✓
• b.Tell the daughter to press it once an hour through the overnight shift.
• c.Thank the daughter for helping the client stay ahead of the pain overnight.
• d.Ask the daughter to press it only when the client moans in pain.

Dosing by anyone other than the client removes the built-in safeguard that a sedated client cannot press the button, and this practice has been documented to cause respiratory depression. Teaching the family before and during therapy that only the client presses the button is the intervention; setting a schedule for the daughter keeps the hazard in place.