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. A client is taking metformin for type 2 diabetes. Which of the following findings should indicate to the nurse that the medication is effective?

• A. Increased urine output
• B. Decreased fasting blood glucose
• C. Decreased hemoglobin A1C
• D. Decreased polyuria

Correct answer: C

Rationale: A decrease in hemoglobin A1C is a more specific indicator of metformin's effectiveness in controlling blood glucose levels over a longer period compared to fasting blood glucose levels. Hemoglobin A1C reflects average blood sugar levels over the past 2-3 months, providing a more comprehensive view of glycemic control. Increased urine output (choice A) is not a direct indicator of metformin's effectiveness and can be influenced by various factors. Decreased fasting blood glucose (choice B) can fluctuate due to various reasons and may not provide a reliable long-term assessment of metformin's efficacy. Decreased polyuria (choice D) refers to a symptom rather than a direct measure of metformin's effectiveness in managing diabetes.

3. A healthcare professional is preparing to initiate IV therapy for an older adult client. Which of the following actions should the professional plan to take?

• A. Use an electric shaver to remove excess hair on the extremity.
• B. Select the antecubital area to insert the IV catheter.
• C. Distend the veins by using a blood pressure cuff.
• D. Instruct the client to keep the extremity still during the procedure.

Correct answer: C

Rationale: Distending the veins using a blood pressure cuff is essential for facilitating visualization and access to the veins during IV catheter insertion. This technique helps healthcare professionals identify suitable veins, reducing the risk of complications like infiltration or hematoma formation. Using an electric shaver to remove hair on the extremity (Choice A) may increase the risk of micro-cuts and introduce infection. Selecting the antecubital area (Choice B) may not always be appropriate, as vein condition and accessibility vary among older adult clients. Instructing the client to keep the extremity still (Choice D) is important but is not directly related to preparing for IV therapy.

4. A client is prescribed Clopidogrel. Which of the following laboratory values should the nurse monitor to assess for potential adverse effects?

• A. White blood cell count
• B. Platelet count
• C. Hemoglobin
• D. Blood glucose

Correct answer: B

Rationale: Clopidogrel is an antiplatelet medication that works by inhibiting platelet aggregation. Therefore, the nurse should monitor the client's platelet count to assess for potential bleeding complications. Changes in platelet count can indicate the effectiveness of Clopidogrel therapy and help prevent adverse effects related to clotting or bleeding. Monitoring white blood cell count, hemoglobin, or blood glucose levels is not directly related to the action or side effects of Clopidogrel.

5. During an assessment, a male client who has recently started taking Haloperidol is displaying certain symptoms. Which of the following findings should the nurse prioritize in reporting to the provider?

• A. Shuffling gait
• B. Neck spasms
• C. Drowsiness
• D. Impotence

Correct answer: B

Rationale: Neck spasms are indicative of acute dystonia, a serious side effect of Haloperidol that requires urgent intervention. Immediate reporting to the provider is crucial to address this potentially harmful condition and ensure the client's safety. Shuffling gait, drowsiness, and impotence are important to monitor but do not pose the same level of immediate risk as acute dystonia. Acute dystonia can lead to serious complications if not promptly treated, making it the priority in this scenario.

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