Nursing Elites

1. A client is prescribed ondansetron for nausea and vomiting. The nurse should monitor the client for which potential adverse effect?

• A. Headache
• B. Diarrhea
• C. Constipation
• D. Increased appetite

Correct answer: C

Rationale: The correct answer is C: Constipation. Ondansetron is known to cause constipation as a potential adverse effect. It is important for the nurse to monitor the client for constipation while on this medication to address any issues promptly. Choices A, B, and D are incorrect because headache, diarrhea, and increased appetite are not common adverse effects associated with ondansetron.

2. A client with rheumatoid arthritis is prescribed methotrexate. What is the most important instruction the practical nurse (PN) should provide to the client?

• A. Take the medication on an empty stomach.
• B. Avoid taking folic acid supplements.
• C. Report any signs of infection immediately.
• D. Increase intake of vitamin C-rich foods.

Correct answer: C

Rationale: Correct Answer: The most important instruction for a client taking methotrexate is to report any signs of infection immediately. Methotrexate can suppress the immune system, making the client more susceptible to infections. Early detection and treatment of infections are crucial to prevent complications. Instructing the client to be vigilant for signs of infection empowers them to take prompt action, enhancing their overall safety and well-being.

3. A client is receiving heparin to treat a deep vein thrombosis. The nurse should monitor which laboratory result to assist in evaluating the efficacy of the drug?

• A. Platelet count
• B. Prothrombin time
• C. Partial thromboplastin time
• D. Serum levels of protamine sulfate

Correct answer: C

Rationale: The nurse should monitor the partial thromboplastin time to evaluate the efficacy of heparin. Partial thromboplastin time reflects the anticoagulant effect of heparin by measuring the intrinsic pathway of coagulation. Platelet count assesses platelet levels and is not specific to heparin efficacy. Prothrombin time is used to monitor warfarin therapy. Serum levels of protamine sulfate are not used to evaluate the efficacy of heparin.

4. In the immediate postoperative period, a client is prescribed morphine via a patient-controlled analgesia (PCA) pump. Which finding should the PN consider the highest priority in this client?

• A. Monitoring the expiration date of the PCA morphine
• B. Assessing the rate and depth of the client's respirations
• C. Reviewing the type of anesthesia used during the surgery
• D. Observing the client's signs of disorientation

Correct answer: B

Rationale: The highest priority for the PN is to assess the rate and depth of the client's respirations when a client is receiving morphine via a PCA pump. Respiratory depression is a life-threatening side effect of intravenous morphine administration. If the client's respiratory rate falls below 10 breaths/min, the PCA pump should be stopped, and the healthcare provider must be notified immediately to prevent further complications. Monitoring the expiration date of the PCA morphine is important but not the highest priority compared to assessing respiratory status. Reviewing the type of anesthesia used during the surgery is not directly related to the immediate management of the client receiving morphine via PCA. Observing signs of disorientation is also important but not as critical as assessing respirations for potential respiratory depression.

5. A client with angina pectoris has been prescribed nitroglycerin tablets prn for chest pain. Which statement by the client causes the practical nurse (PN) to clarify instructions for this client?

• A. I will take one tablet every 5 minutes, up to three tablets.
• B. I should take one tablet at the onset of angina and stop activity.
• C. I need to replace nitroglycerin tablets every 3 to 6 months to maintain freshness.
• D. I should ensure that I chew the pill completely before swallowing it.

Correct answer: D

Rationale: Nitroglycerin tablets should be taken at the onset of angina, and the client should stop activity and rest. One tablet should be placed under the tongue (sublingually), not chewed or swallowed. One tablet can be taken every 5 minutes, up to three doses. If pain relief not achieved after taking three pills, seek medical attention immediately. Nitroglycerin should be replaced every 3 to 6 months. Nitroglycerin pain relief should occur in 5 minutes and duration should last 30 minutes.

Similar Questions