Nursing Elites

1. A client with diabetes mellitus type 2 is prescribed saxagliptin. The nurse should include which instruction in the client's teaching plan?

• A. Report any signs of pancreatitis to the healthcare provider.
• B. Take this medication with meals.
• C. Avoid alcohol while taking this medication.
• D. Report any signs of heart failure to the healthcare provider.

Correct answer: A

Rationale: Corrected Rationale: When a client with diabetes mellitus type 2 is prescribed saxagliptin, it is crucial to instruct them to report any signs of pancreatitis to the healthcare provider. Saxagliptin can lead to pancreatitis as a side effect, making it essential for clients to be vigilant about recognizing and reporting any related symptoms promptly for timely intervention and management. Choice B is incorrect because saxagliptin can be taken with or without meals. Choice C is not specifically associated with saxagliptin use. Choice D is incorrect as heart failure is not a common side effect of saxagliptin.

2. 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.

3. A 6-month-old infant is prescribed digoxin for the treatment of congestive heart failure. Which observation by the practical nurse (PN) warrants immediate intervention for signs of digoxin toxicity?

• A. Apical heart rate of 60 beats/min
• B. Sweating across the forehead
• C. Poor sucking effort
• D. Respiratory rate of 30 breaths/min

Correct answer: A

Rationale: A heart rate of 60 beats/min for a 6-month-old infant warrants immediate intervention as it falls below the normal range. The normal heart rate for a 6-month-old is 80 to 150 beats/min when awake, and a rate of 70 beats/min while sleeping is considered within normal limits. Bradycardia (heart rate <60 beats/min) in infants can be a sign of digoxin toxicity, necessitating prompt evaluation and intervention to prevent adverse effects. Sweating across the forehead (Choice B) is a non-specific symptom and may not directly indicate digoxin toxicity. Poor sucking effort (Choice C) and a respiratory rate of 30 breaths/min (Choice D) are not typically associated with digoxin toxicity and do not require immediate intervention in the context of this question.

4. A client with pulmonary tuberculosis has been taking rifampin for 3 weeks. The client reports orange urine. What should be the nurse's next action?

• A. Notify the client's health care provider.
• B. Inform the client that this is not harmful.
• C. Assess the client for other signs of nephrotoxicity.
• D. Monitor the client's most recent creatinine level.

Correct answer: B

Rationale: The correct action for the nurse to take when a client reports orange urine after taking rifampin is to inform the client that this change is not harmful. Rifampin is known to cause orange discoloration of urine, which is a harmless side effect. There is no need to notify the health care provider as this is an expected outcome. Monitoring creatinine levels or assessing for nephrotoxicity is unnecessary in this situation, as rifampin does not typically cause kidney damage.

5. A postoperative client has a prescription for ketorolac 30mg IV q6h. Which response demonstrates that therapeutic levels of the medication have been achieved?

• A. Observe wound drainage for a change in appearance
• B. Assess the client's calves for inflammation
• C. Perform a pain assessment using a numeric scale
• D. Measure the client's intake and output

Correct answer: C

Rationale: The correct response is to perform a pain assessment using a numeric scale. Ketorolac is an NSAID prescribed for pain relief. Monitoring pain levels is crucial to evaluate the therapeutic effectiveness of the medication. Pain assessment helps determine if the medication is providing adequate pain relief, indicating that therapeutic levels have been achieved.

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