Nursing Elites

1. A client is to receive Tetracaine before a Bronchoscopy. Which of the following actions should the nurse include in the plan of care?

• A. Keep the client NPO until the pharyngeal response returns.
• B. Monitor the insertion site for a hematoma.
• C. Palpate the bladder to detect urinary retention.
• D. Maintain the client on bed rest for 12 hours following the procedure.

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care is to keep the client NPO until the pharyngeal response returns. Tetracaine can affect the gag reflex, so it is important to prevent aspiration by maintaining the client NPO until the pharyngeal response is normal, which typically takes about 1 hour. Monitoring for the return of the gag reflex is crucial to prevent complications from aspiration during the first oral intake after the procedure. Choices B, C, and D are incorrect because they are not directly related to the effects of Tetracaine or the bronchoscopy procedure.

2. A client with schizophrenia is being taught strategies to cope with anticholinergic effects of Fluphenazine. Which of the following should the nurse suggest to the client to minimize anticholinergic effects?

• A. Take the medication in the morning to prevent insomnia.
• B. Chew sugarless gum to moisten the mouth.
• C. Use cooling measures to decrease fever.
• D. Take an antacid to relieve nausea.

Correct answer: B

Rationale: Chewing sugarless gum is an effective strategy to manage dry mouth, a common anticholinergic effect of Fluphenazine. By stimulating saliva production, sugarless gum helps to moisten the mouth and alleviate the discomfort associated with dryness. This intervention can improve the client's oral health and overall comfort while taking the medication. The other options are not directly related to alleviating anticholinergic effects. Taking the medication in the morning to prevent insomnia does not address anticholinergic effects specifically. Using cooling measures to decrease fever is not relevant to managing dry mouth caused by anticholinergic effects. Taking an antacid to relieve nausea is unrelated to managing dry mouth, which is the focus of anticholinergic effects.

3. When teaching a client with a new prescription for Amiodarone, which instruction should the nurse include?

• A. Take this medication with meals.
• B. Avoid drinking grapefruit juice.
• C. Take this medication at bedtime.
• D. Increase your intake of sodium-rich foods.

Correct answer: B

Rationale: The correct instruction is to avoid drinking grapefruit juice when taking Amiodarone. Grapefruit juice can inhibit the metabolism of Amiodarone, leading to increased blood levels of the drug and potentially causing adverse effects like cardiac toxicity. Choices A, C, and D are incorrect because taking Amiodarone with meals, at bedtime, or increasing sodium-rich foods intake are not relevant instructions for this medication.

4. A client has been prescribed Valsartan. Which of the following adverse effects should the nurse monitor?

• A. Hyperkalemia
• B. Hypoglycemia
• C. Bradycardia
• D. Hypercalcemia

Correct answer: A

Rationale: Corrected Rationale: Valsartan is an angiotensin II receptor blocker (ARB) that can lead to hyperkalemia by inhibiting the action of aldosterone. Hyperkalemia is a potential adverse effect, making it essential for the nurse to closely monitor the client's potassium levels to prevent complications such as cardiac arrhythmias. Incorrect Options Rationale: - Option B, Hypoglycemia, is not a common adverse effect of Valsartan. - Option C, Bradycardia, is not typically associated with Valsartan use. - Option D, Hypercalcemia, is not a known adverse effect of Valsartan; instead, Valsartan can lead to hyperkalemia.

5. A client is taking Epoetin Alfa for anemia. Which of the following laboratory tests should the nurse monitor to evaluate the effectiveness of the therapy?

• A. White blood cell count
• B. Platelet count
• C. Hematocrit
• D. Serum potassium level

Correct answer: C

Rationale: The nurse should monitor the hematocrit level to evaluate the effectiveness of Epoetin Alfa therapy since it stimulates red blood cell production. Hematocrit reflects the volume of red blood cells in the blood, providing a direct measure of the therapy's impact on increasing red blood cell mass and addressing anemia. Monitoring white blood cell count and platelet count is not directly related to assessing the effectiveness of Epoetin Alfa therapy for anemia. Serum potassium level monitoring may be necessary due to potential side effects of the medication, but it is not the primary indicator of therapy effectiveness in treating anemia.

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