Nursing Elites

1. While teaching a client with a new prescription for Warfarin, which of the following statements by the client indicates a need for further teaching?

• A. I will avoid eating large amounts of green leafy vegetables.
• B. I will take my medication at the same time every day.
• C. I will increase my intake of foods high in potassium.
• D. I will report any signs of bleeding to my provider.

Correct answer: C

Rationale: The correct answer is C because Warfarin interacts with vitamin K, found in green leafy vegetables, not potassium. The client should avoid consuming large amounts of foods high in vitamin K to maintain the effectiveness of Warfarin therapy. Increasing potassium intake is not a concern related to Warfarin therapy, so this statement indicates a need for further teaching. Choices A, B, and D are all correct statements indicating good understanding of Warfarin therapy. Avoiding large amounts of green leafy vegetables helps prevent fluctuations in vitamin K levels, taking medication consistently maintains therapeutic levels, and reporting any signs of bleeding is essential for monitoring and managing potential side effects of Warfarin.

2. When a client reports urticaria and dyspnea after receiving amoxicillin/clavulanic acid, which medication should be administered first?

• A. Administer epinephrine
• B. Administer albuterol
• C. Administer diphenhydramine
• D. Administer prednisone

Correct answer: A

Rationale: In the scenario described, the client is experiencing symptoms of a severe allergic reaction. The priority intervention is to administer epinephrine. Epinephrine acts quickly to reverse the effects of the allergic reaction and can be life-saving in cases of anaphylaxis. Albuterol is used for bronchodilation and may help with respiratory symptoms but is not the first-line treatment for anaphylaxis. Diphenhydramine and prednisone are used for allergic reactions but are not as rapid-acting as epinephrine and should be considered after administering epinephrine in this situation.

3. A client is receiving chemotherapy and has a prescription for ondansetron IV for nausea and vomiting. The nurse should monitor the client for which of the following adverse effects?

• A. Hypotension
• B. Bradycardia
• C. Tremors
• D. Urinary retention

Correct answer: C

Rationale: The correct answer is C: Tremors. Ondansetron can cause tremors as an adverse effect. Monitoring for tremors is essential as it can indicate a potential adverse reaction to the medication. Hypotension (choice A) and bradycardia (choice B) are not commonly associated with ondansetron. Urinary retention (choice D) is also not a typical adverse effect of ondansetron, making choices A, B, and D incorrect in this scenario.

4. A client is being discharged with a new prescription for Fluoxetine for PTS. Which of the following statements should the nurse include in the teaching?

• A. You may experience a decreased desire for intimacy while taking this medication.
• B. You should take this medication in the morning to avoid sleep disturbances.
• C. To minimize urinary adverse effects, ensure you urinate before taking this medication.
• D. It is recommended to wear sunglasses outdoors due to the light sensitivity caused by this medication.

Correct answer: A

Rationale: The correct statement for the nurse to include in the teaching is that the client may experience a decreased desire for intimacy while taking Fluoxetine for PTS. This is important because Fluoxetine, an SSRI used to treat PTS, can lead to decreased libido as a potential adverse effect. Choices B, C, and D are incorrect because they do not address the specific side effect associated with Fluoxetine and are not directly relevant to the medication's effects for this patient.

5. A client with active tuberculosis asks why he must take four different medications. Which of the following responses should the nurse make?

• A. Four medications decrease the risk of a severe allergic reaction.
• B. Four medications reduce the chance that the bacteria will become resistant.
• C. Four medications reduce the risk of adverse reactions.
• D. Four medications decrease the chance of having a positive tuberculin skin test.

Correct answer: B

Rationale: The correct answer is B. When treating tuberculosis, using a combination of medications is crucial to reduce the risk of bacteria developing resistance to any single drug. This approach helps prevent treatment failure and ensures successful treatment outcomes. Choice A is incorrect because the primary purpose of using multiple medications is not related to allergic reactions. Choice C is incorrect as the risk reduction is mainly focused on bacterial resistance rather than adverse reactions. Choice D is not relevant as the purpose of taking multiple medications is not to affect the tuberculin skin test results.

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