Anticoagulants, insulin, opioids and other high-alert drugs

64 NCLEX-RN practice questions on Anticoagulants, insulin, opioids and other high-alert drugs, part of Pharmacological and Parenteral Therapies. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium · Matrix

   A client is receiving oxycodone after surgery. For each finding, indicate whether it is an expected effect to manage routinely or one that needs immediate intervention.

   For each row, choose: Expected, manage routinely / Requires immediate intervention

   1. No bowel movement for 2 days
   2. SpO2 85% while asleep, with pauses in breathing
   3. Respiratory rate 8/min and hard to rouse
   4. Nausea after the first dose
   5. Mild itching of the face

   Show answerHide answer

   Answer:

   • No bowel movement for 2 days: Expected, manage routinely
   • SpO2 85% while asleep, with pauses in breathing: Requires immediate intervention
   • Respiratory rate 8/min and hard to rouse: Requires immediate intervention
   • Nausea after the first dose: Expected, manage routinely
   • Mild itching of the face: Expected, manage routinely

   Analyse cues: constipation, mild itching and early nausea are expected and managed. Sedation with a slow respiratory rate, apnea or hypoxemia needs immediate action: stimulate the client, stop the opioid, give oxygen and prepare naloxone.

   • No bowel movement for 2 days: Constipation is expected and is treated with a scheduled bowel regimen.
   • SpO2 85% while asleep, with pauses in breathing: Hypoxemia and apnea during sleep mean the opioid effect is dangerous.
   • Respiratory rate 8/min and hard to rouse: Deep sedation with slow breathing signals respiratory depression.
   • Nausea after the first dose: Nausea is common early and usually fades or responds to an antiemetic.
   • Mild itching of the face: Mild pruritus is a common effect of opioid histamine release.

2. Question 2 · Medium · Select all that apply

   The nurse teaches a client who is starting oral extended-release potassium chloride tablets. Which instructions should the nurse include?

   1. AReport black stools or new abdominal pain
   2. BTake each dose with food and a full glass of water
   3. CSwallow the tablet whole without crushing or chewing it
   4. DTake the tablet on an empty stomach at bedtime
   5. EAvoid salt substitutes unless the provider approves

   Show answerHide answer

   Answer: A, B, C, E

   Generate solutions: oral potassium is irritant, so it is taken whole with food and water while upright. Salt substitutes add potassium, and GI bleeding or pain must be reported.

   • D: An empty stomach and lying down increase GI irritation and esophageal injury.

3. Question 3 · Hard · Select all that apply

   A client with type 1 diabetes is NPO from midnight for a morning procedure. The usual regimen is insulin glargine at 2100 and insulin aspart with meals. Which actions should the nurse take?

   1. AKeep a fast-acting glucose treatment available
   2. BGive the usual aspart dose with the morning medications
   3. CCheck capillary glucose at the intervals set by the protocol
   4. DOmit all insulin until the client is eating again
   5. EClarify a reduced dose of glargine with the provider
   6. FHold the meal-time aspart while the client is NPO

   Show answerHide answer

   Answer: A, C, E, F

   Generate solutions: type 1 diabetes always needs basal insulin, so it is reduced, not omitted, while prandial insulin is held during fasting. Regular glucose checks and a ready hypoglycemia treatment complete the plan.

   • B: Rapid-acting insulin without food causes hypoglycemia within 1-2 hours.
   • D: A client with type 1 diabetes has no insulin of their own; omitting basal insulin can cause ketoacidosis.

4. Question 4 · Hard · Matrix

   A client with preeclampsia has received magnesium sulfate 2 g/h for 6 hours. For each finding, indicate whether it is an expected effect or a sign of toxicity.

   For each row, choose: Expected effect / Sign of toxicity

   1. Serum magnesium 6 mEq/L (protocol range 4-7 mEq/L)
   2. Feels warm and flushed
   3. Urine output 20 mL/h for 2 hours
   4. Patellar reflexes 2+ bilaterally
   5. Respiratory rate 10/min
   6. Patellar reflexes absent

   Show answerHide answer

   Answer:

   • Serum magnesium 6 mEq/L (protocol range 4-7 mEq/L): Expected effect
   • Feels warm and flushed: Expected effect
   • Urine output 20 mL/h for 2 hours: Sign of toxicity
   • Patellar reflexes 2+ bilaterally: Expected effect
   • Respiratory rate 10/min: Sign of toxicity
   • Patellar reflexes absent: Sign of toxicity

   Evaluate outcomes: flushing, normal reflexes and a level in range are expected. Absent reflexes, respiratory depression and low urine output signal toxicity, and the infusion is stopped with calcium gluconate ready.

   • Serum magnesium 6 mEq/L (protocol range 4-7 mEq/L): This is within the therapeutic range.
   • Feels warm and flushed: Vasodilation causes flushing and warmth, especially early.
   • Urine output 20 mL/h for 2 hours: Oliguria lets magnesium build up to toxic levels.
   • Patellar reflexes 2+ bilaterally: Normal reflexes show no toxicity.
   • Respiratory rate 10/min: Respiratory depression is a sign of high magnesium levels.
   • Patellar reflexes absent: Loss of reflexes is the earliest reliable sign of toxicity.

5. Question 5 · Hard · Select all that apply

   A client with alcohol use disorder has a potassium of 3.0 mEq/L that has not risen after two days of oral replacement, and a magnesium of 1.1 mg/dL (reference 1.7-2.2 mg/dL). Which actions should the nurse take?

   1. APlace the client on cardiac monitoring
   2. BExpect the potassium to correct with a larger oral dose alone
   3. CAssess for tremor, hyperreflexia and a positive Chvostek sign
   4. DGive potassium chloride by IV push to correct it faster
   5. EAnticipate IV magnesium replacement along with the potassium

   Show answerHide answer

   Answer: A, C, E

   Analyse cues: refractory hypokalemia points to hypomagnesemia, common in alcohol use disorder. The nurse anticipates magnesium replacement, monitors the cardiac rhythm and assesses for neuromuscular irritability.

   • B: Potassium replacement fails while magnesium remains low.
   • D: IV push potassium can cause cardiac arrest.

6. Question 6 · Easy · Select all that apply

   The nurse prepares to give IV potassium chloride to a client with hypokalemia. Which actions are safe?

   1. AGive it by IV push over 1 minute
   2. BConfirm adequate urine output before starting
   3. CUse a premixed bag supplied by pharmacy
   4. DAdd potassium to the bag that is already running
   5. EGive the infusion on an electronic infusion pump
   6. FRun 40 mEq through a peripheral line in 30 minutes

   Answer and explanation in LearnFree account

7. Question 7 · Easy · Select all that apply

   The nurse teaches a client who is starting insulin vials at home how to store them. Which instructions are correct?

   1. AKeep a spare vial in the freezer
   2. BStore the vial in use at room temperature
   3. CLeave the vial in the car during summer trips
   4. DKeep unopened vials in the refrigerator
   5. EWrite the date opened on the vial
   6. FDiscard rapid-acting insulin that looks cloudy

   Answer and explanation in LearnFree account

8. Question 8 · Hard · Select all that apply

   A client on methadone maintenance, 90 mg daily from an outpatient program, is admitted for an open abdominal operation. Which plans should the nurse expect?

   1. AExpect a higher requirement for additional opioid analgesia
   2. BGive naloxone with each opioid dose as a precaution
   3. CMonitor sedation level and respiratory rate closely
   4. DWithhold all opioids to prevent a relapse
   5. EUse scheduled nonopioid analgesics alongside the opioids
   6. FContinue the usual daily methadone dose after verifying it with the program

   Answer and explanation in LearnFree account

9. Question 9 · Medium · Matrix

   The nurse reviews anticoagulant monitoring for several clients. For each therapy, indicate the coagulation test usually used to adjust the dose.

   For each row, choose: aPTT or anti-Xa level / INR / No routine coagulation test

   1. Warfarin for atrial fibrillation
   2. Heparin 5,000 units subcutaneously every 8 hours
   3. Apixaban for atrial fibrillation
   4. Enoxaparin 40 mg subcutaneously daily for prophylaxis
   5. Continuous IV unfractionated heparin

   Answer and explanation in LearnFree account

10. Question 10 · Medium · Select all that apply

    A client with severe preeclampsia is to start IV magnesium sulfate. Which actions should the nurse take when setting up the infusion?

    1. AAssess deep tendon reflexes once per shift
    2. BGive the loading dose by IV push over 1 minute
    3. CMeasure urine output hourly through an indwelling catheter
    4. DHang the magnesium as the only IV line
    5. ERun the magnesium as a secondary infusion on a pump
    6. FAssess respirations, reflexes and level of consciousness at set intervals

    Answer and explanation in LearnFree account

11. Question 11 · Medium · Select all that apply

    The nurse is reviewing clients prescribed IV opioids after surgery. Which factors increase a client's risk of opioid-induced respiratory depression?

    1. AWalking in the hallway three times a day
    2. BObstructive sleep apnea
    3. CNo opioid use before this admission
    4. DAge of 78 years
    5. EDaily opioid use for 2 years at a stable dose
    6. FLorazepam given at bedtime

    Answer and explanation in LearnFree account

12. Question 12 · Hard · Select all that apply

    A heparin infusion was stopped for major bleeding, and the provider prescribes IV protamine sulfate. Which actions should the nurse take?

    1. AGive the dose by deep intramuscular injection
    2. BAsk about fish allergy and past use of NPH insulin
    3. CGive the dose slowly over about 10 minutes
    4. DExplain that it will also reverse the client's warfarin
    5. EPush the whole dose rapidly to stop the bleeding sooner

    Answer and explanation in LearnFree account

13. Question 13 · Hard · Select all that apply

    A client on a continuous IV regular insulin infusion in the intensive care unit is receiving continuous tube feeding, which is stopped for a CT scan. Which actions should the nurse take?

    1. AGive a bolus of regular insulin before transport
    2. BContinue the same insulin rate without changes
    3. CAdjust the infusion or start dextrose as the protocol directs
    4. DStop the insulin and leave it off until the next day
    5. ECheck capillary glucose now and then at the protocol's closer intervals

    Answer and explanation in LearnFree account

14. Question 14 · Medium · Select all that apply

    A client is starting a continuous IV heparin infusion for a deep vein thrombosis. Which actions should the nurse include in the plan of care?

    1. AUse a soft toothbrush and an electric razor
    2. BGive ibuprofen as needed for leg pain
    3. CCheck the aPTT or anti-Xa level after each rate change as set by protocol
    4. DHave a second nurse independently verify the dose and pump settings
    5. ERun the infusion on an electronic infusion pump
    6. FInspect urine, stools and gums for bleeding

    Answer and explanation in LearnFree account

15. Question 15 · Hard · Matrix

    A client with a serum potassium of 2.9 mEq/L is receiving potassium chloride 10 mEq/h through a peripheral IV line. For each finding, indicate the nurse's action.

    For each row, choose: Continue the infusion / Pause the infusion and report

    1. Repeat potassium 3.3 mEq/L after two bags
    2. New tall, peaked T waves on the monitor
    3. Urine output 15 mL/h for the past 2 hours
    4. Mild ache at the IV site that settles when the rate is slowed per policy
    5. Severe burning with redness along the vein

    Answer and explanation in LearnFree account

16. Question 16 · Medium · Matrix

    The nurse checks the INR goal written for several clients taking warfarin. For each indication, indicate the usual target INR range.

    For each row, choose: INR 2.0-3.0 / INR 2.5-3.5

    1. Atrial fibrillation without a valve replacement
    2. Mechanical aortic valve plus atrial fibrillation
    3. Pulmonary embolism after hip surgery
    4. Mechanical mitral valve replacement
    5. Treatment of a deep vein thrombosis

    Answer and explanation in LearnFree account

17. Question 17 · Hard · Matrix

    A client with type 2 diabetes who takes metoprolol daily has received insulin and missed a meal. For each sign of hypoglycemia, indicate whether the nurse should expect it to be present or blunted by the beta blocker.

    For each row, choose: Likely still present / Likely blunted

    1. Confusion
    2. Sweating
    3. Tremor
    4. Tachycardia
    5. Palpitations
    6. Hunger

    Answer and explanation in LearnFree account

18. Question 18 · Medium · Select all that apply

    The nurse teaches the family of a client discharged on long-term opioids how to use nasal naloxone. Which instructions should the nurse include?

    1. ACall 911 as soon as you find the person unresponsive
    2. BGive a second dose in the other nostril if there is no response in 2-3 minutes
    3. CWait to see if the person wakes up before calling for help
    4. DSpray one dose into one nostril with the person lying on the back
    5. ETurn the person onto the side once breathing returns
    6. FStay with the person until help arrives

    Answer and explanation in LearnFree account

19. Question 19 · Medium · Select all that apply

    A client is prescribed insulin lispro 6 units with lunch using a prefilled pen. Which actions should the nurse take?

    1. AMassage the site firmly after the injection
    2. BDial and dispense a 2-unit priming dose before the dose
    3. CHold the pen in the skin for a count of 10 after injecting
    4. DAspirate before injecting to check for blood
    5. EUse the pen for a second client after fitting a new needle

    Answer and explanation in LearnFree account

20. Question 20 · Hard · Matrix

    A client's heparin protocol has an aPTT target of 60-85 seconds: below 60, rebolus and increase the rate; 60-85, no change; above 85, decrease the rate. For each result, indicate the nurse's action.

    For each row, choose: Continue at the current rate / Change the rate per protocol / Stop the infusion and notify the provider

    1. aPTT 76 seconds, new coffee-ground emesis
    2. aPTT 52 seconds, no bleeding
    3. aPTT 71 seconds, no bleeding
    4. aPTT 93 seconds, no bleeding

    Answer and explanation in LearnFree account

21. Question 21 · Hard · Select all that apply

    The nurse reviews new prescriptions on a surgical unit. Which prescriptions should the nurse question before giving them?

    1. AHeparin 5,000 units subcutaneously every 8 hours
    2. BPotassium chloride 20 mEq IV push now
    3. CFentanyl 25 mcg/h transdermal patch for acute pain in an opioid-naive client
    4. DInsulin glargine 20 units mixed with insulin aspart 6 units in one syringe
    5. EMagnesium sulfate 2 g/h IV on an infusion pump
    6. FInsulin lispro 4 units subcutaneously with each meal

    Answer and explanation in LearnFree account

22. Question 22 · Hard · Matrix

    At the start of a shift, the nurse reviews six clients receiving high-alert drugs. For each client, indicate whether the finding requires immediate follow-up.

    For each row, choose: Requires immediate follow-up / Does not require immediate follow-up

    1. Morphine PCA, respiratory rate 9/min, difficult to rouse
    2. Insulin glargine given at 2100, bedtime glucose 132 mg/dL
    3. Magnesium sulfate infusion, patellar reflexes absent
    4. Potassium chloride infusion, potassium 3.2 mEq/L up from 2.8
    5. Heparin infusion, aPTT 68 seconds (target 60-85)
    6. Insulin aspart given 20 minutes ago, tray not arrived, glucose 70 mg/dL and sweaty

    Answer and explanation in LearnFree account

23. Question 23 · Medium · Matrix

    The nurse reviews the timing of insulin doses for clients on a medical unit. For each insulin, indicate when it is usually given in relation to meals.

    For each row, choose: Within 15 minutes of a meal / About 30 minutes before a meal / Same time daily, not tied to a meal

    1. Insulin aspart
    2. Regular insulin
    3. Insulin glargine
    4. Insulin lispro

    Answer and explanation in LearnFree account

24. Question 24 · Medium · Matrix

    A nurse is preparing a reference card on anticoagulant reversal. For each anticoagulant, indicate the specific reversal agent.

    For each row, choose: Protamine sulfate / Idarucizumab / Andexanet alfa

    1. Dabigatran
    2. Unfractionated heparin
    3. Enoxaparin
    4. Rivaroxaban
    5. Apixaban

    Answer and explanation in LearnFree account

25. Question 25 · Medium · Select all that apply

    A client takes warfarin for atrial fibrillation with an INR target of 2-3. During a clinic visit, which findings require follow-up?

    1. ATakes acetaminophen for knee pain
    2. BEats one serving of spinach most days
    3. CBlack, tarry stools for the past 2 days
    4. DINR of 2.6
    5. ENew headache that is worse than usual
    6. FSmall bruise on the shin after a bump

    Answer and explanation in LearnFree account