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 a new prescription for clonidine to treat hypertension. Which of the following instructions should the nurse include?

• A. Discontinue the medication if a rash develops.
• B. Expect increased salivation during the first few weeks of therapy.
• C. Avoid driving until the client's reaction to the medication is known.
• D. Stop the medication if you experience a dry mouth.

Correct answer: C

Rationale: The correct instruction for a client starting clonidine therapy for hypertension is to avoid driving until their reaction to the medication is known. Clonidine can cause drowsiness, so it is important for the client to refrain from activities that require alertness until they are aware of how the medication affects them. Choice A is incorrect because a rash is not a common side effect of clonidine. Choice B is incorrect as increased salivation is not an expected side effect of clonidine. Choice D is also incorrect as dry mouth is a common side effect of clonidine, but it is not a reason to stop the medication unless severe or bothersome. Therefore, the priority instruction for the nurse to include is to advise the client to avoid driving until their reaction to the medication is known to ensure safety.

3. A healthcare professional is preparing to administer Spironolactone to a client. Which of the following laboratory results should the professional review before administering this medication?

• A. Serum potassium.
• B. Serum sodium.
• C. Serum chloride.
• D. Serum calcium.

Correct answer: A

Rationale: When administering Spironolactone, it is essential to monitor the client's serum potassium levels because Spironolactone is a potassium-sparing diuretic. Monitoring potassium levels helps to detect hyperkalemia, a potential adverse effect of the medication.

4. The client makes which statement about lifestyle changes to reduce the development and progression of coronary artery disease that indicates the need for further teaching?

• A. “I will check my weight regularly for any gain or loss.”
• B. “I’ll make sure to take my high blood pressure medications.”
• C. “I am attending a smoking cessation class.”
• D. “As long as I exercise, stress at my job will not bother me.”

Correct answer: D

Rationale: The client stating, 'As long as I exercise, stress at my job will not bother me,' indicates a misunderstanding of the relationship between exercise and stress management. It is important to clarify that while exercise can help reduce stress, it may not eliminate all stressors, especially those related to work. Further teaching is needed to ensure the client understands the multifactorial approach required to address stress and its impact on coronary artery disease.

5. When assessing a client with chronic Neutropenia receiving Filgrastim, what action should the nurse take to evaluate for an adverse effect of the medication?

• A. Assess for bone pain.
• B. Assess for right lower quadrant pain.
• C. Auscultate for crackles in the bases of the lungs.
• D. Auscultate the chest to listen for a heart murmur.

Correct answer: A

Rationale: The correct action when assessing a client receiving Filgrastim for chronic Neutropenia is to assess for bone pain. Bone pain is a known dose-related adverse effect of Filgrastim. Acetaminophen or opioid analgesics can be used to manage bone pain if necessary. Assessing for other types of pain, lung crackles, or heart murmurs would not be specific to the adverse effects of Filgrastim.

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