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 has been prescribed Methotrexate to treat Rheumatoid Arthritis. Which of the following instructions should the nurse provide?

• A. Take this medication with food to prevent nausea.
• B. Avoid alcohol while taking this medication.
• C. Wear sunscreen when outdoors while taking this medication.
• D. Take this medication on an empty stomach.

Correct answer: B

Rationale: Methotrexate is hepatotoxic, and avoiding alcohol is crucial to prevent liver damage. However, Option A (Take this medication with food to prevent nausea) could also be correct, as Methotrexate commonly causes nausea, and taking it with food can help alleviate this side effect. However, the most important instruction is to avoid alcohol due to the risk of liver toxicity.

3. While caring for a client receiving Heparin therapy, which of the following laboratory tests should the nurse monitor to evaluate the effectiveness of the therapy?

• A. PT
• B. INR
• C. aPTT
• D. Platelet count

Correct answer: C

Rationale: The nurse should monitor the aPTT (activated partial thromboplastin time) when caring for a client receiving Heparin therapy. The aPTT reflects the intrinsic pathway of the clotting cascade and is used to monitor the effectiveness of heparin, which primarily affects this pathway by potentiating antithrombin III. Monitoring the aPTT helps ensure that the client's blood is within the therapeutic range to prevent thrombus formation. Choices A, B, and D are incorrect. PT (Prothrombin Time) and INR (International Normalized Ratio) are used to monitor Warfarin therapy, not Heparin. Platelet count is important in assessing for thrombocytopenia but is not a specific indicator of Heparin therapy effectiveness.

4. A client with HIV is starting therapy with zidovudine. The nurse should monitor the client for which of the following adverse effects of this medication?

• A. Fatigue
• B. Blurred vision
• C. Ringing in the ears
• D. Constipation

Correct answer: A

Rationale: Fatigue is a common adverse effect of zidovudine due to its impact on bone marrow, leading to anemia. Zidovudine is known to cause bone marrow suppression, resulting in decreased production of red blood cells and subsequent fatigue.

5. A client with Peptic Ulcer Disease who is taking Sucralfate PO has a new prescription for phenytoin to control seizures. Which of the following instructions should the nurse include?

• A. Take an antacid with the sucralfate.
• B. Take sucralfate with a glass of milk.
• C. Allow a 2-hour interval between these medications.
• D. Chew the sucralfate thoroughly before swallowing.

Correct answer: C

Rationale: Sucralfate can interfere with the absorption of phenytoin. To prevent this interaction, the client should allow a 2-hour interval between taking sucralfate and phenytoin. This interval helps ensure that each medication is absorbed effectively without affecting the other's absorption. Choices A, B, and D are incorrect because taking an antacid with sucralfate, taking sucralfate with a glass of milk, or chewing sucralfate thoroughly before swallowing are not necessary or recommended instructions to prevent the interaction between sucralfate and phenytoin.

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