Nursing Elites

1. A client with breast cancer is receiving cyclophosphamide. What finding should the nurse monitor for?

• A. Hypertension
• B. Hyperglycemia
• C. Ototoxicity
• D. Hemorrhagic cystitis

Correct answer: D

Rationale: When a client is receiving cyclophosphamide, the nurse should monitor for hemorrhagic cystitis, a severe adverse effect caused by bladder irritation. It is essential to watch for signs such as hematuria, dysuria, and urinary frequency, and promptly intervene to prevent further complications. Hypertension (Choice A) is not typically associated with cyclophosphamide use. Hyperglycemia (Choice B) is not a common side effect of cyclophosphamide. Ototoxicity (Choice C) is more commonly associated with medications like aminoglycoside antibiotics or high-dose aspirin.

2. A hospitalized client has an activated partial thromboplastin time (aPTT) greater than 1.5 times the expected reference range. Which of the following blood products should be prepared for transfusion?

• A. Whole blood
• B. Platelets
• C. Fresh frozen plasma
• D. Packed red blood cells

Correct answer: C

Rationale: Fresh frozen plasma is the appropriate blood product for a client with an elevated aPTT as it contains various coagulation factors that can help correct coagulopathies and prevent bleeding. Elevated aPTT indicates a deficiency in specific clotting factors, and fresh frozen plasma is rich in these factors. Whole blood, platelets, and packed red blood cells do not contain the necessary coagulation factors to correct an elevated aPTT, so they are not indicated in this situation.

3. A client has a new prescription for Aspirin for the prevention of myocardial infarction. Which of the following findings should be identified as an adverse effect?

• A. Nausea
• B. Bruising
• C. Dizziness
• D. Dry mouth

Correct answer: B

Rationale: Bruising is an adverse effect to be monitored when a client is prescribed Aspirin for the prevention of myocardial infarction due to its association with increased bleeding risk. Aspirin's antiplatelet effect can lead to bruising and other signs of bleeding, necessitating close observation to prevent complications. Nausea, dizziness, and dry mouth are not typically recognized adverse effects of Aspirin therapy for myocardial infarction prevention.

4. A client has a new prescription for rituximab. Which of the following findings should the nurse instruct the client to report?

• A. Dizziness
• B. Fever
• C. Urinary frequency
• D. Dry mouth

Correct answer: B

Rationale: The nurse should instruct the client to report fever. Fever can be an indication of an infection, a potential complication of rituximab therapy. Monitoring and reporting fever promptly can help in early intervention to prevent further complications. Dizziness, urinary frequency, and dry mouth are not typically associated with rituximab therapy and are less likely to be directly related to the medication. Therefore, they are not the priority findings to report in this scenario.

5. A client is receiving Morphine IV for pain management. Which of the following actions should the nurse take to monitor for adverse effects?

• A. Monitor the client's respiratory rate every 15 minutes.
• B. Monitor the client's blood pressure every 30 minutes.
• C. Monitor the client's oxygen saturation every hour.
• D. Monitor the client's heart rate every 5 minutes.

Correct answer: A

Rationale: The correct action for the nurse to monitor for adverse effects of Morphine IV is to check the client's respiratory rate every 15 minutes. Respiratory depression is a potentially life-threatening adverse effect of Morphine. Monitoring the respiratory rate frequently allows for early detection and intervention if needed. Monitoring blood pressure, oxygen saturation, or heart rate alone may not provide early signs of respiratory depression, which is a critical adverse effect of Morphine IV.

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