Nursing Elites

1. When a nurse assesses a client's IV catheter insertion site and notes a hematoma, which of the following actions should the nurse take? (Select all that apply.)

• A. Stop the infusion.
• B. Apply alcohol to the insertion site.
• C. Apply warm compresses to the insertion site.
• D. Elevate the client's arm.

Correct answer: C

Rationale: When a nurse detects a hematoma at the IV catheter insertion site, applying warm compresses is beneficial as it can promote healing by enhancing circulation and reducing swelling. Elevating the client's arm helps in reducing edema, which can relieve pressure, pain, and further bleeding in the hematoma area. Stopping the infusion may be necessary in certain situations, but it is not a standard action for all hematoma cases. Applying alcohol to the insertion site is discouraged as it can cause irritation and may not aid in resolving the hematoma.

2. A client has a new prescription for methotrexate to treat Rheumatoid Arthritis. The nurse should expect to monitor the client for which of the following adverse effects?

• A. Insomnia
• B. Hypertension
• C. Bone marrow suppression
• D. Constipation

Correct answer: C

Rationale: The correct answer is bone marrow suppression (Choice C). Methotrexate can lead to bone marrow suppression, resulting in adverse effects such as anemia, leukopenia, and thrombocytopenia. Monitoring for signs of decreased blood cell counts is essential to prevent complications and adjust treatment as needed. Choices A, B, and D are incorrect. Insomnia, hypertension, and constipation are not typically associated with methotrexate use in the treatment of Rheumatoid Arthritis.

3. While caring for a client receiving IV heparin, which of the following findings should the nurse identify as an adverse effect of this medication?

• A. Hypertension
• B. Hyperglycemia
• C. Thrombocytopenia
• D. Leukopenia

Correct answer: C

Rationale: Thrombocytopenia, a decrease in platelet count, is a known adverse effect associated with heparin therapy. It can lead to an increased risk of bleeding and should be closely monitored during treatment. Choices A, B, and D are incorrect. Hypertension is not typically associated with heparin use; hyperglycemia is not a common adverse effect of heparin; leukopenia is not a primary side effect of heparin therapy.

4. When teaching a client who has a new prescription for Ciprofloxacin, which of the following instructions should the nurse include?

• A. Take this medication with an antacid.
• B. Avoid direct sunlight.
• C. Increase your intake of dairy products.
• D. Expect urine to turn orange.

Correct answer: B

Rationale: The correct instruction for a client prescribed Ciprofloxacin is to avoid direct sunlight. Ciprofloxacin can cause photosensitivity, increasing the risk of sunburn. Clients should be advised to avoid direct sunlight and wear protective clothing, including hats and sunglasses when going outdoors to prevent skin damage. Choices A, C, and D are incorrect. Taking Ciprofloxacin with an antacid can reduce its absorption, so they should not be taken together. Increasing dairy product intake is not necessary or relevant to taking Ciprofloxacin. While Ciprofloxacin can discolor urine, turning it orange, this is not a critical side effect that requires specific instructions for the client.

5. A client is prescribed Clopidogrel. Which of the following laboratory values should the nurse monitor to assess for potential adverse effects?

• A. White blood cell count
• B. Platelet count
• C. Hemoglobin
• D. Blood glucose

Correct answer: B

Rationale: Clopidogrel is an antiplatelet medication that works by inhibiting platelet aggregation. Therefore, the nurse should monitor the client's platelet count to assess for potential bleeding complications. Changes in platelet count can indicate the effectiveness of Clopidogrel therapy and help prevent adverse effects related to clotting or bleeding. Monitoring white blood cell count, hemoglobin, or blood glucose levels is not directly related to the action or side effects of Clopidogrel.

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