Nursing Elites

1. A client receiving IV heparin reports abdominal pain and tarry stools. What is the nurse's priority action?

• A. Prepare to administer protamine sulfate.
• B. Continue the heparin infusion and notify the healthcare provider.
• C. Monitor the client's vital signs and assess abdominal pain.
• D. Administer a PRN dose of morphine sulfate.

Correct answer: A

Rationale: The correct answer is to prepare to administer protamine sulfate. Abdominal pain and tarry stools are indicative of gastrointestinal bleeding, a serious side effect of heparin therapy. Protamine sulfate is the antidote for heparin and is used to reverse its effects in cases of bleeding. Continuing the heparin infusion (Choice B) is not appropriate when the client is experiencing signs of bleeding. Monitoring vital signs and assessing abdominal pain (Choice C) is important but not the priority when immediate action is required to address potential bleeding. Administering morphine sulfate (Choice D) is not the priority in this situation; addressing the underlying cause of bleeding takes precedence.

2. A client with psoriasis is prescribed topical corticosteroids. What side effect should the nurse monitor for?

• A. Monitor for weight gain and skin thinning.
• B. Assess for increased sensitivity to sunlight.
• C. Monitor for hair loss and excessive bruising.
• D. Report any signs of increased redness or itching.

Correct answer: D

Rationale: The correct answer is D. When a client with psoriasis is prescribed topical corticosteroids, the nurse should monitor for signs of increased redness or itching. This is because topical corticosteroids can cause skin thinning and increased redness if overused. Choices A, B, and C are incorrect because weight gain, sensitivity to sunlight, hair loss, and excessive bruising are not typically associated with the use of topical corticosteroids.

3. A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?

• A. Assess for signs of infection.
• B. Monitor the client’s fluid intake and output.
• C. Check the client’s capillary blood glucose level.
• D. Assess the client’s serum potassium level.

Correct answer: C

Rationale: The correct answer is to check the client’s capillary blood glucose level first. In a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, assessing blood glucose levels is crucial to confirm hyperglycemia and initiate appropriate interventions. While signs of infection are important to assess due to the client's postoperative status and diabetic history, checking the blood glucose level takes precedence to address the immediate concern of hyperglycemia. Monitoring fluid intake and output is essential but not the priority in this scenario. Assessing the client’s serum potassium level is important for overall assessment but not the initial step when hyperglycemia is suspected.

4. The nurse leading a medical-surgical unit care team assigns client care to a PN and a UAP. Which task should the nurse delegate to the UAP?

• A. Assess a client's pain level post-surgery
• B. Turn and reposition a client with a total hip replacement
• C. Administer a dose of insulin per sliding scale
• D. Change a postoperative dressing

Correct answer: B

Rationale: Turning and repositioning a client is within the scope of practice of a UAP. This task helps prevent pressure ulcers and assists in maintaining the client's comfort and mobility. Assessing pain level post-surgery requires clinical judgment and interpretation, making it appropriate for a PN or RN. Administering medication like insulin involves critical thinking and potential adjustments based on the client's condition, which is the responsibility of a licensed nurse. Changing postoperative dressings involves wound assessment, infection control, and knowledge of aseptic techniques, tasks that fall under the purview of a PN or RN.

5. A client with a recent myocardial infarction is prescribed a beta-blocker. What side effect should the nurse monitor for?

• A. Monitor the client for bradycardia.
• B. Check the client’s blood pressure for signs of hypotension.
• C. Monitor the client for signs of hyperglycemia.
• D. Monitor for signs of fluid retention.

Correct answer: B

Rationale: The correct answer is B: 'Check the client’s blood pressure for signs of hypotension.' Beta-blockers can lead to decreased heart rate, but bradycardia is not the primary side effect to monitor. Monitoring for bradycardia is more relevant when administering medications like digoxin. Hyperglycemia is associated with medications like corticosteroids, not beta-blockers. Fluid retention is a side effect seen with medications like corticosteroids or calcium channel blockers, not beta-blockers. Therefore, in a client taking a beta-blocker after a myocardial infarction, monitoring for hypotension is crucial due to the medication's mechanism of action.

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