Nursing Elites

1. What is the primary nursing intervention that the practical nurse should perform before administering ampicillin to a client diagnosed with a urinary tract infection?

• A. Obtain a clean-catch urine specimen.
• B. Assess the urine pH for acidity.
• C. Insert an indwelling catheter.
• D. Assess for complaints of dysuria.

Correct answer: A

Rationale: The correct answer is to obtain a clean-catch urine specimen. Before administering ampicillin to a client with a urinary tract infection, it is crucial to collect a urine specimen to determine the causative organism and evaluate the effectiveness of pharmacological therapy. Assessing the urine pH for acidity (choice B) is not the primary intervention needed before administering ampicillin. Inserting an indwelling catheter (choice C) is invasive and not necessary unless indicated for specific reasons. Assessing for complaints of dysuria (choice D) is important but does not take precedence over obtaining a urine specimen for proper diagnosis and treatment.

2. A client who takes metformin for diabetes mellitus type 2 is nothing by mouth (NPO) for surgery. What pre-op prescription should the practical nurse (PN) anticipate for this client's glucose management?

• A. NPO except for metformin and regular snacks
• B. NPO except for oral antidiabetic agent
• C. Novolin-N insulin subcutaneously twice daily
• D. Regular insulin subcutaneously per sliding scale

Correct answer: D

Rationale: When a client taking metformin for diabetes mellitus type 2 is NPO for surgery, it is crucial to manage their glucose levels effectively. The best approach in this situation is to prescribe regular insulin subcutaneously according to a sliding scale based on the client's blood glucose levels. This method allows for precise adjustment of insulin doses to maintain blood glucose within the target range while the client is unable to take oral medications. Choices A and B are incorrect because metformin is typically held when a client is NPO, and oral antidiabetic agents may not provide sufficient glucose control. Choice C is incorrect as Novolin-N insulin given twice daily may not offer the flexibility needed for glucose management in a surgical setting where the client's intake is restricted.

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

• A. Weight gain
• B. Dry mouth
• C. Nausea
• D. Headache

Correct answer: A

Rationale: When a client is prescribed risperidone, it is essential to monitor for potential side effects. Weight gain is a common side effect of risperidone, so the nurse should closely monitor the client's weight throughout the treatment. This monitoring helps in early detection of weight changes and allows for timely interventions to prevent further complications.

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. A client with a diagnosis of generalized anxiety disorder is prescribed diazepam. The nurse should instruct the client that this medication may have which potential side effect?

• A. Drowsiness
• B. Dry mouth
• C. Nausea
• D. Headache

Correct answer: A

Rationale: Correct. Diazepam, a medication commonly used to treat anxiety disorders, can lead to drowsiness as a potential side effect. It is important for clients taking diazepam to be cautious about activities that require alertness, such as driving, due to the risk of drowsiness associated with this medication. Choice B, dry mouth, is not typically associated with diazepam use. Choice C, nausea, is less common as a side effect of diazepam compared to drowsiness. Choice D, headache, is also less common and typically not a significant side effect of diazepam.

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