Question

A nurse is assessing a female client.

Answer 1

Correct Highlights :

Client is currently taking lisinopril 5 mg PO daily.
Potassium 5.6 mEq/L (3.5 to 5 mEq/L)
BUN 30 mg/dL (10 to 20 mg/dL)
Creatine 3 mg/dL (0.5 to 1 mg/dL)

Rationale :

Current lisinopril use

🟢 The client is already taking lisinopril, which is an ACE inhibitor.

🟢ACE inhibitors can increase serum potassium by decreasing aldosterone effects.

🟢Spironolactone is a potassium-sparing diuretic, so combining it with lisinopril increases the risk for dangerous hyperkalemia.

🟢Hyperkalemia can cause cardiac dysrhythmias, muscle weakness, and cardiac arrest if severe.

🟢The nurse should report this medication combination to the provider before teaching or administering the new prescription.

Potassium 5.6 mEq/L

🟢 A potassium level of 5.6 mEq/L is elevated above the normal range.

🟢 Spironolactone can further increase potassium because it prevents potassium loss in the urine.

🟢 Giving spironolactone to a client who already has hyperkalemia can worsen the potassium elevation.

🟢 Elevated potassium is especially dangerous because it can affect cardiac conduction.

🟢 This finding is a major contraindication and must be reported to the provider.

BUN 30 mg/dL

🟢A BUN of 30 mg/dL is elevated and suggests impaired kidney function or decreased renal perfusion.

🟢Kidney impairment reduces the body’s ability to regulate potassium and eliminate medications effectively.

🟢Spironolactone use in renal impairment increases the risk for hyperkalemia and medication accumulation.

🟢This finding is concerning when combined with elevated creatinine and high potassium.

🟢The nurse should report the abnormal renal value before the client starts spironolactone.

Creatinine 3 mg/dL

🟢A creatinine level of 3 mg/dL is significantly elevated and indicates impaired renal function.

🟢Spironolactone should be used cautiously or avoided in clients with significant renal impairment.

🟢Poor kidney function increases the risk for potassium retention, especially with potassium-sparing medications.

🟢This client already has hyperkalemia, making the renal impairment even more concerning.

🟢The nurse should notify the provider because spironolactone could worsen electrolyte imbalance and cause serious complications.

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Answer 2

Correct Answers

Blank 1 Correct Option: capillary glucose
Blank 2 Correct Option: blood pressure

Rationale :

Capillary glucose

🟢The client’s capillary glucose is 64 mg/dL, which indicates hypoglycemia.

🟢Hypoglycemia is the priority because it can quickly lead to confusion, seizures, loss of consciousness, or neurologic injury if untreated.

🟢The nurse should hold the scheduled insulin aspart and treat the low glucose according to protocol.

🟢 Insulin aspart is rapid-acting, so giving it when the blood glucose is already low could worsen hypoglycemia.

🟢The nurse should reassess the glucose after treatment before administering any diabetes medication.

Blood pressure

🟢 The client’s blood pressure is 90/70 mm Hg, which is low and should be addressed before giving metoprolol.

🟢 Metoprolol is a beta-blocker that can lower blood pressure and heart rate.

🟢 Administering metoprolol with a low blood pressure could worsen hypotension, dizziness, weakness, or poor perfusion.

🟢 The nurse should hold the medication and notify the provider according to facility policy or prescribed parameters.

🟢 Blood pressure is addressed after the glucose because hypoglycemia is the more immediate safety risk.

Reported pain

🟢A pain rating of 4/10 should be assessed and managed, but it is not the first priority.

🟢Hypoglycemia and low blood pressure create more immediate medication safety concerns.

Temperature

🟢A temperature of 38.2°C/100.8°F is elevated and consistent with pneumonia.

🟢It needs monitoring and treatment, but it is not more urgent than hypoglycemia before rapid-acting insulin.

Lung auscultation findings

🟢Scattered rhonchi are expected with pneumonia and productive cough.

🟢The client’s respirations are even and non-labored with oxygen saturation 97%, so this is not the priority over glucose and blood pressure.

Heart rate

🟢A heart rate of 104/min is mildly elevated and may relate to fever, infection, pain, or hypoglycemia.

🟢It is less concerning than the low blood pressure before metoprolol administration.

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Answer 3

Correct Answers

Administer hydralazine IV. [ Inappropriate ]
Administer sodium polystyrene rectally. [ Appropriate ]
Administer calcium gluconate IV. [ Appropriate ]
Administer insulin IV. [ Appropriate ]
Administer potassium chloride IV. [ Inappropriate ]

Rationale :

Appropriate

Administer sodium polystyrene rectally

🟢The client has hyperkalemia with a potassium level of 6 mEq/L.

🟢Sodium polystyrene helps remove excess potassium from the body through the gastrointestinal tract.

🟢Rectal administration may be used when rapid potassium removal is needed or when oral administration is not preferred.

🟢This prescription supports lowering potassium and reducing the risk for dangerous cardiac complications.

🟢The nurse should monitor bowel function, potassium levels, and the client’s overall response to therapy.

Administer calcium gluconate IV

🟢 Calcium gluconate IV is appropriate because the client has ECG changes from hyperkalemia, including peaked T waves and absent P waves.

🟢 Calcium gluconate does not lower potassium, but it stabilizes the cardiac membrane.

🟢 This helps reduce the risk for life-threatening dysrhythmias while other treatments lower the potassium level.

🟢 The client’s irregular heart rate and ECG findings make this a priority intervention.

🟢 The nurse should administer it as prescribed and continue cardiac monitoring.

Administer insulin IV

🟢IV insulin is appropriate because it helps shift potassium from the bloodstream into the cells.

🟢This rapidly lowers the serum potassium level temporarily and protects the client while potassium is removed from the body.

🟢Insulin is commonly given with dextrose to prevent hypoglycemia, depending on the prescription and blood glucose level.

🟢This intervention is important because the client has symptomatic hyperkalemia with muscle weakness, tingling, and ECG changes.

🟢The nurse should monitor blood glucose, potassium level, and cardiac rhythm closely.

Inappropriate

Administer hydralazine IV

🟢Hydralazine is an antihypertensive medication, but this client’s blood pressure is not dangerously elevated.

🟢The priority problem is hyperkalemia with ECG changes, not hypertension.

Administer potassium chloride IV

🟢Potassium chloride would worsen the client’s already elevated potassium level of 6 mEq/L.

🟢Giving potassium in hyperkalemia can cause severe dysrhythmias or cardiac arrest.

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Answer 4

Correct Answers

Current heart rate [ Expected ]
Reported urinary concern [ Expected ]
Reported current leg findings [ Expected ]
Current potassium level [ Unexpected ]
Digoxin level [ Expected ]

Rationale :

Current heart rate — Expected

🔴The client’s heart rate decreased from 106/min to 82/min, which is an expected response to digoxin therapy.

🔴Digoxin improves cardiac output and slows conduction through the AV node.

🔴In heart failure, improved pumping ability can reduce compensatory tachycardia.

🔴A heart rate of 82/min is within an acceptable adult range.

🔴This finding suggests the medication is helping improve cardiac function without causing bradycardia.

Reported urinary concern — Expected

🔴Increased daily urinary output is expected when heart failure symptoms improve.

🔴As cardiac output improves, kidney perfusion increases, allowing the body to remove excess fluid more effectively.

🔴This can lead to decreased fluid overload and improved breathing.

🔴The client’s report of less shortness of breath supports improved fluid balance.

🔴This finding indicates a positive therapeutic response to heart failure treatment.

Reported current leg findings — Expected

🔴Decreased leg swelling is expected because improved cardiac function reduces fluid retention.

🔴In heart failure, edema occurs when the heart cannot pump effectively and fluid backs up into tissues.

🔴Improved cardiac output helps reduce venous congestion and peripheral edema.

🔴The client’s report that the legs are not as swollen suggests improved heart failure status.

🔴This is an expected therapeutic response to digoxin therapy.

Current potassium level — Unexpected

🔴The potassium level of 3.2 mEq/L is low and is an unexpected finding that requires follow-up.

🔴Hypokalemia increases the risk of digoxin toxicity, even when the digoxin level is within the therapeutic range.

🔴Low potassium can make the heart more sensitive to digoxin effects and increase the risk for dysrhythmias.

🔴The nurse should report this potassium level and assess for weakness, cramps, palpitations, nausea, vomiting, or visual changes.

🔴Potassium correction may be needed to safely continue digoxin therapy.

Digoxin level — Expected

🔴 The digoxin level is 0.8 ng/mL, which is within the listed therapeutic range of 0.8 to 2 ng/mL.

🔴 A therapeutic digoxin level supports medication effectiveness while reducing toxicity risk.

🔴 The client’s improved heart rate, breathing, urine output, and edema also support a positive response.

🔴 Even with a therapeutic level, the nurse must still monitor for toxicity because low potassium increases risk.

🔴 This finding is expected, but it should be interpreted together with the abnormal potassium level.

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Answer 5

Correct Answers:

Aspirin
Heparin
Morphine

Rationale :

Aspirin

🟢The client has findings consistent with an acute ST-elevation myocardial infarction.

🟢Aspirin is expected because it decreases platelet aggregation and helps prevent further clot formation.

🟢ST-segment elevation in multiple leads and elevated troponin 0.67 ng/mL indicate myocardial injury.

🟢Aspirin is usually given early in suspected myocardial infarction unless contraindicated.

🟢This medication helps reduce the risk of worsening coronary artery blockage.

Heparin

🟢 Heparin is expected because it helps prevent clot extension during an acute myocardial infarction.

🟢 It works as an anticoagulant and reduces further thrombus formation in the coronary circulation.

🟢 The client has crushing chest pain, shortness of breath, nausea, ST elevation, and elevated troponin, which support acute coronary syndrome.

🟢 Heparin may be used along with reperfusion therapy such as PCI depending on facility protocol and provider orders.

🟢 The nurse should monitor for bleeding, platelet count changes, and anticoagulation parameters as prescribed.

Morphine

🟢Morphine may be prescribed for severe chest pain that is not relieved by first-line interventions.

🟢It decreases pain and anxiety, which can reduce sympathetic stimulation and myocardial oxygen demand.

🟢Morphine can also cause venodilation, which may reduce preload and cardiac workload.

🟢The nurse should monitor blood pressure, respirations, sedation level, and pain response after administration.

🟢This medication is appropriate when carefully used for persistent ischemic chest pain.

Dopamine

🟢Dopamine is used for severe hypotension or shock to improve blood pressure and perfusion.

🟢This client’s blood pressure is stable at 136/80 to 138/78 mm Hg, so dopamine is not expected.

Digoxin

🟢Digoxin is used for heart failure and certain atrial dysrhythmias, not as an acute treatment for STEMI.

🟢It does not relieve coronary artery blockage or treat acute clot formation.

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Answer 6

Correct Answers:

"Pinch up a skin area before injection."
"Inject the medication at a 90-degree angle."
"Rotate injection sites."

Rationale :

“Pinch up a skin area before injection.”

🟣Enoxaparin is administered into the subcutaneous tissue, usually in the abdomen.

🟣Pinching up a fold of skin helps ensure the medication is delivered into fatty tissue rather than muscle.

🟣Subcutaneous administration promotes proper absorption and reduces injection-related injury.

🟣The client should keep the skin fold pinched throughout the injection.

🟣This technique supports safe self-administration of a low-molecular-weight heparin.

“Inject the medication at a 90-degree angle.”

🟣Enoxaparin is usually injected at a 90-degree angle into the subcutaneous tissue.

🟣A 90-degree angle helps the needle enter the fatty layer directly when using prefilled syringes.

🟣The client should inject slowly and steadily to reduce discomfort.

🟣The medication should not be injected into muscle because this increases bleeding and hematoma risk.

🟣This instruction supports correct technique and safer anticoagulant administration.

“Rotate injection sites.”

🟣 The client should rotate injection sites to reduce bruising, tenderness, irritation, and tissue damage.

🟣 Enoxaparin is commonly injected in the right or left side of the abdomen, at least 2 inches from the umbilicus.

🟣 Rotation prevents repeated trauma to the same area.

🟣 The client should avoid bruised, scarred, hardened, or irritated skin.

🟣 This helps maintain safe absorption and reduces local injection complications.

“Rub the injection area after administration.”

🟣The client should not rub or massage the injection site after enoxaparin.

🟣Rubbing increases the risk for bruising and bleeding.

“Expel the air bubble in the syringe before administration.”

🟣The client should not expel the air bubble from a prefilled enoxaparin syringe.

🟣The air bubble helps deliver the full dose and reduces medication tracking through tissue.

“Inject the medication in your upper arm muscle.”

🟣Enoxaparin should not be injected into muscle because it is a subcutaneous anticoagulant.

🟣Intramuscular injection increases the risk for bleeding and hematoma formation.

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Answer 7

Correct Answers:

Potassium chloride

Rationale :

🔷 Lisinopril is an ACE inhibitor that can increase serum potassium levels.

🔷 Potassium chloride is a potassium supplement, so taking it with lisinopril can increase the risk for hyperkalemia.

🔷 Hyperkalemia can cause muscle weakness, cardiac conduction changes, dysrhythmias, and cardiac arrest.

🔷 The nurse should consult the provider before administering potassium chloride with lisinopril.

🔷 The client’s potassium level should be monitored closely if therapy continues.

Acetaminophen

🔷Acetaminophen does not commonly cause a dangerous interaction with lisinopril.

🔷It may be used for pain or fever as prescribed.

Levothyroxine

🔷Levothyroxine is a thyroid hormone replacement medication.

🔷It is not contraindicated with lisinopril.

Metformin

🔷Metformin is used to manage type 2 diabetes mellitus.

🔷It does not create the same hyperkalemia risk as potassium chloride.

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Answer 8

Correct Answers:

The client had chemotherapy 12 hr before the medication was administered.

Rationale :

🟢 Filgrastim should not be administered within 24 hr before or after cytotoxic chemotherapy.

🟢 Giving filgrastim too close to chemotherapy can increase damage to rapidly dividing bone marrow cells.

🟢 Since the client received chemotherapy only 12 hr before filgrastim, this is a medication timing error.

🟢 The nurse should complete an incident report according to facility policy.

🟢 The provider should also be notified, and the client should be monitored for adverse outcomes.

The client had a decreased neutrophil count before the medication was administered.

🟢A decreased neutrophil count is an expected reason for giving filgrastim.

🟢Filgrastim stimulates neutrophil production after chemotherapy-related bone marrow suppression.

The vial was out of the refrigerator for 2 hr before the medication was administered.

🟢Filgrastim can generally be kept at room temperature for a limited period depending on product guidance.

🟢Two hours out of the refrigerator is not the key error in this scenario.

The client reported feeling nauseous after the medication was administered.

🟢Nausea can occur in clients receiving chemotherapy and other medications.

🟢This requires assessment and symptom management, but it does not automatically require an incident report.

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Answer 9

Correct Answers:

Fluid retention

Rationale :

🟣 Desmopressin is an antidiuretic hormone replacement used to reduce excessive urination in diabetes insipidus.

🟣 Because it promotes water reabsorption, the client is at risk for fluid retention.

🟣 Excess water retention can lead to hyponatremia, headache, confusion, weight gain, and seizures.

🟣 The nurse should monitor intake and output, daily weight, edema, sodium level, and neurologic status.

🟣 This adverse effect is important because overcorrection can cause water intoxication.

Bradycardia

🟣Bradycardia is not the main adverse effect expected with desmopressin.

🟣The priority concern is excess water retention and low sodium.

Hypernatremia

🟣Desmopressin usually lowers the risk of hypernatremia by reducing water loss.

🟣The adverse effect of concern is hyponatremia from retaining too much water.

Blurred vision

🟣Blurred vision is not the primary adverse effect of desmopressin.

🟣Fluid overload and sodium imbalance are more important to monitor.

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Answer 10

Correct Answers:

"The TPN will provide nutrients while your bowels have time to rest."

Rationale :

🔶 Total parenteral nutrition provides nutrients directly into the bloodstream through IV therapy.

🔶 It is used when the gastrointestinal tract cannot be used or needs time to rest.

🔶 TPN contains nutrients such as glucose, amino acids, lipids, electrolytes, vitamins, and trace elements.

🔶 It helps prevent malnutrition when oral or enteral intake is not possible or not sufficient.

🔶 This teaching is accurate because TPN bypasses the digestive tract while still meeting nutritional needs.

“The TPN will help keep your bowels clear in case you need surgery.”

🔶TPN does not clear the bowels.

🔶It provides nutrition through the bloodstream.

“The TPN contains medication that will help your digestive tract absorb nutrients.”

🔶TPN does not improve digestive absorption.

🔶It bypasses the gastrointestinal tract entirely.

“The TPN will stimulate your appetite so that you'll be able to eat more food.”

🔶TPN is not used to stimulate appetite.

🔶It is used to provide nutrition when the client cannot meet needs through the GI tract.

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Provider Prescription	Appropriate	Inappropriate
Administer hydralazine IV.
Administer sodium polystyrene rectally.
Administer calcium gluconate IV.
Administer insulin IV.
Administer potassium chloride IV.

Potential Finding	Expected	Unexpected
Current heart rate
Reported urinary concern
Reported current leg findings
Current potassium level
Digoxin level

QLexNursing

1 :
A nurse is assessing a female client.

Correct Highlights :

2 :
A nurse is preparing to administer a medication to a client.

Correct Answers

3 :
A nurse in an emergency department (ED) is caring for a female client.

Correct Answers

4 :
A nurse is caring for a client in a provider's office.

Correct Answers

5 :
A nurse is caring for a client in an emergency department (ED).

Answer Options

6 :
A nurse is caring for a client.

Answer Options

7 :
A nurse is caring for a client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about a contraindication for which of the following medications in the client's medication administration record?

8 :
A nurse is reviewing the medical record of a client who just received a dose of IV filgrastim. The client has cancer and is receiving cytotoxic chemotherapy. For which of the following findings should the nurse complete an incident report?

9 :
A nurse is administering desmopressin to a client who has diabetes insipidus. The nurse should monitor the client for which of the following adverse effects?

10 :
A nurse is teaching a client who has a new prescription for total parenteral nutrition (TPN). Which of the following information should the nurse include in the teaching?

QLexNursing

1 : A nurse is assessing a female client.

Correct Highlights :

2 : A nurse is preparing to administer a medication to a client.

Correct Answers

3 : A nurse in an emergency department (ED) is caring for a female client.

Correct Answers

4 : A nurse is caring for a client in a provider's office.

Correct Answers

5 : A nurse is caring for a client in an emergency department (ED).

Answer Options

6 : A nurse is caring for a client.

Answer Options

7 : A nurse is caring for a client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about a contraindication for which of the following medications in the client's medication administration record?

8 : A nurse is reviewing the medical record of a client who just received a dose of IV filgrastim. The client has cancer and is receiving cytotoxic chemotherapy. For which of the following findings should the nurse complete an incident report?

9 : A nurse is administering desmopressin to a client who has diabetes insipidus. The nurse should monitor the client for which of the following adverse effects?

10 : A nurse is teaching a client who has a new prescription for total parenteral nutrition (TPN). Which of the following information should the nurse include in the teaching?

1 :
A nurse is assessing a female client.

2 :
A nurse is preparing to administer a medication to a client.

3 :
A nurse in an emergency department (ED) is caring for a female client.

4 :
A nurse is caring for a client in a provider's office.

5 :
A nurse is caring for a client in an emergency department (ED).

6 :
A nurse is caring for a client.

7 :
A nurse is caring for a client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about a contraindication for which of the following medications in the client's medication administration record?

8 :
A nurse is reviewing the medical record of a client who just received a dose of IV filgrastim. The client has cancer and is receiving cytotoxic chemotherapy. For which of the following findings should the nurse complete an incident report?

9 :
A nurse is administering desmopressin to a client who has diabetes insipidus. The nurse should monitor the client for which of the following adverse effects?

10 :
A nurse is teaching a client who has a new prescription for total parenteral nutrition (TPN). Which of the following information should the nurse include in the teaching?