Nursing Elites

1. In the emergency department, a child is admitted for accidental ingestion of a poison. The practical nurse (PN) should know that inducing vomiting is recommended for which child?

• A. An 8-month-old who ingested four to six ibuprofen tablets
• B. A 3-year-old who drank an unknown amount of charcoal lighter fluid
• C. A 16-month-old who ingested 2 ounces of acetaminophen elixir
• D. A 2-year-old who ate a handful of automatic dishwasher detergent

Correct answer: C

Rationale: Inducing emesis is recommended for the child who ingested a large dose of acetaminophen elixir because this medication is hepatotoxic. Acetaminophen overdose can lead to severe liver damage, and prompt removal from the stomach can help reduce absorption and potential harm.

2. A client with a history of atrial fibrillation is prescribed warfarin. The nurse should monitor for which sign of potential bleeding?

• A. Elevated blood pressure
• B. Bruising
• C. Shortness of breath
• D. Nausea and vomiting

Correct answer: B

Rationale: Warfarin is an anticoagulant that increases the risk of bleeding. Bruising is a common sign of potential bleeding in clients taking warfarin. Monitoring for bruising is essential as it can indicate a risk of bleeding that needs further assessment and management. Elevated blood pressure, shortness of breath, nausea, and vomiting are not direct signs of potential bleeding associated with warfarin therapy.

3. A client with a diagnosis of schizophrenia is prescribed aripiprazole. The nurse should monitor the client for which potential side effect?

• A. Weight gain
• B. Dry mouth
• C. Headache
• D. Increased appetite

Correct answer: A

Rationale: Aripiprazole is known to cause weight gain in patients, so monitoring for changes in weight is essential to assess for this potential side effect and intervene accordingly.

4. A client with type 2 diabetes mellitus is prescribed exenatide. The nurse should monitor for which potential adverse effect?

• A. Nausea
• B. Hypoglycemia
• C. Hyperglycemia
• D. Pancreatitis

Correct answer: A

Rationale: Exenatide, a medication commonly used in type 2 diabetes, is known to cause gastrointestinal side effects, such as nausea. Monitoring for nausea is essential as it can lead to decreased appetite and potential weight loss, affecting the nutritional status of the client. While hypoglycemia and hyperglycemia are important to monitor in diabetes management, they are not typically associated with exenatide use. Pancreatitis is a rare but serious adverse effect of exenatide, which requires immediate medical attention if suspected.

5. The practical nurse administers lactulose to a client. Which client outcome would indicate a therapeutic response?

• A. An increase in urine output
• B. Two to three soft stools per day
• C. Absence of nausea
• D. Decreased serum potassium

Correct answer: B

Rationale: Lactulose is a type of laxative that works by preventing the absorption of ammonia in the colon, leading to increased water absorption in the stool and softening of the stool. The therapeutic response to lactulose is indicated by the passage of two to three soft stools per day, showing that the medication is effectively promoting bowel movements.

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