Nursing Elites

1. A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?

• A. Instruct the client to self-ambulate every 2 hours.
• B. Offer oral hygiene every 2 hours.
• C. Anticipate medication administration 2 hours prior to delivery.
• D. Monitor fetal heart rate every 2 hours.

Correct answer: B

Rationale: When a client is receiving IV Opioid analgesics during labor, the nurse should offer oral hygiene every 2 hours. Opioid analgesics can cause adverse effects like dry mouth, nausea, and vomiting. Providing oral hygiene care helps alleviate these symptoms and maintains the client's comfort and well-being during labor. Instructing the client to self-ambulate every 2 hours is not appropriate during labor as mobility may be limited. Anticipating medication administration 2 hours prior to delivery is not necessary as the timing of medication administration should be based on the client's needs and the progress of labor. Monitoring fetal heart rate every 2 hours is important during labor, but it is not specifically related to the client receiving IV Opioid analgesics.

2. When does regular insulin typically peak?

• A. 30 minutes to 2 ½ hours
• B. 1 to 3 hours
• C. 6 to 14 hours
• D. 1 to 5 hours

Correct answer: D

Rationale: Regular insulin usually peaks around 1 to 5 hours after administration. This peak time frame is important to consider when managing blood glucose levels and timing meals to coincide with insulin activity. Choice A, '30 minutes to 2 ½ hours,' is incorrect because regular insulin typically peaks later. Choice B, '1 to 3 hours,' is not the most accurate as the peak for regular insulin can extend beyond 3 hours. Choice C, '6 to 14 hours,' is incorrect as this timeframe is more indicative of long-acting insulins, not regular insulin.

3. A healthcare professional is reviewing the medical history of a client who has a new prescription for Metformin to treat type 2 diabetes. Which of the following findings should the healthcare professional report to the provider?

• A. Hemoglobin A1C of 7.5%
• B. Creatinine level of 1.2 mg/dL
• C. BUN level of 18 mg/dL
• D. Liver function tests showing AST of 50 units/L

Correct answer: D

Rationale: The correct answer is D. Elevated AST levels in liver function tests should be reported to the provider when a client is prescribed Metformin due to the potential risk of hepatotoxicity associated with the medication. Elevated Hemoglobin A1C (choice A), Creatinine level within normal range (choice B), and BUN level within normal range (choice C) are not directly concerning when initiating Metformin therapy.

4. Which statement is true about food and drug precautions?

• A. Limiting certain types of food or administering certain types of drugs is necessary.
• B. Certain combinations of food and drugs can cause adverse reactions.
• C. Precautions may involve limiting certain types of food or administering drugs rather than restricting the drug itself.
• D. When one drug alters the way another drug affects the body.

Correct answer: B

Rationale: The correct answer is B. Certain combinations of food and drugs can indeed lead to adverse reactions. It is important to be cautious with the simultaneous intake of food and drugs as interactions between them can affect their efficacy and safety. Choices A, C, and D are incorrect because they do not accurately reflect the potential risks associated with the combination of food and drugs.

5. When a nurse assesses a client's IV catheter insertion site and notes a hematoma, which of the following actions should the nurse take? (Select all that apply.)

• A. Stop the infusion.
• B. Apply alcohol to the insertion site.
• C. Apply warm compresses to the insertion site.
• D. Elevate the client's arm.

Correct answer: C

Rationale: When a nurse detects a hematoma at the IV catheter insertion site, applying warm compresses is beneficial as it can promote healing by enhancing circulation and reducing swelling. Elevating the client's arm helps in reducing edema, which can relieve pressure, pain, and further bleeding in the hematoma area. Stopping the infusion may be necessary in certain situations, but it is not a standard action for all hematoma cases. Applying alcohol to the insertion site is discouraged as it can cause irritation and may not aid in resolving the hematoma.

Similar Questions